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Handbook of Therapy 



FOURTH EDITION 

EDITED AND REVISED 



OLIVER T. OSBORNE, M.D. 

NEW HAVEN, CONN. 



MORRIS FISHBEIN, M.D. 

CHICAGO 

JEROME H. SALISBURY, M.D. 

CHICAGO 



1915 

AMERICAN MEDICAL ASSOCIATION 
535 NORTH DEARBORN STREET, CHICAGO 






Copyright, 1915 

BY THE 

American Medical Association 



©UA411S96 

OCT II 1915 



PREFACE 

The matter which appeared in the Therapeutic 
Department of The Journal of the American Medical 
Association has been widely commended. The first 
three editions of the Handbook of Therapy were 
based wholly on these articles. Advances in therapeu- 
tics have necessitated new articles at various times, 
and requests have been received for a revised edition 
of the book. In the preparation of this edition, only 
the most recent articles in the Therapeutic Department 
have been included. Where no recent article on any 
given subject w 7 as available, notably the gastrointes- 
tinal diseases, the skin diseases, kidney disturbances 
and some of the acute infections, new T articles have 
been prepared. In this work the collaboration of Dr. 
Jerome H. Salisbury, who died before the completion 
of the book, and of Dr. N. S. Davis III, has been 
helpful. 

Conditions .governing therapeutic requirements are 
stated as clearly and concisely as possible. With rare 
exceptions, the formulas which the book contains are 
combinations which can be easily compounded by any 
pharmacist. 

The form of the book has been made such that it 
can be carried in a satchel or pocket. To enhance its 
value as a handbook, various tables and compilations 
of valuable data have been added. 

Morris Fishbein, M.D. 
Chicago, 1915. . 



CONTENTS 



PAGE 

Preface to the Fourth Edition 5 

Prescription Writing 13 

Introduction 13 

Official Preparations 15 

Thermometric Equivalents 19 

Weights and Measures 19 

Incompatibilities 22 

The Harrison Antinarcotic Law 24 

Latin 25 

Abbreviations L'sed in Prescription Writing 26 

Table of Average Weight to Height at Different Ages 28 

Methods of Administering Drugs 31 

Classification of Drugs 33 

Treatment of Poisoning 36 

New and Nonofficial Remedies 48 

Useful Drugs 55 

General Diseases 66 

Individual Tendencies 66 

Unscientific Prescribing 67 

Pain as a Symptom 68 

Measles 69 

Scarlet Fever 74 

Diphtheria 93 

Laryngeal Diphtheria 106 

Septic Sore Throat 107 

German Measles 108 

Chicken-Pox : Varicella 109 

Mumps 110 

Meningitis 112 

Acute Anterior Poliomyelitis 117 

Hookworm Disease 122 

Typhoid Fever 125 

Rheumatism 139 

Chronic Arthritis 142 

Arthritis Deformans 145 

Tetanus ■ 146 



8 CONTENTS 

PAGE 

Cholera 150 

Pneumonia 152 

Erysipelas 156 

Typhus Fever 158 

Syphilis 159 

Tuberculosis 169 

Pellagra 201 

Diseases of the Respiratory Tract 206 

Acute Coryza 207 

Acute Pharyngitis 213 

Coughs 214 

Acute Bronchitis 217 

Influenza : Grip 219 

Asthma 224 

Hay Fever 233 

Diseases of the Gastro-Intestinal Tract 236 

Hygiene of the Mouth and Teeth 237 

Foul Breath 239 

Mouth-Washes and Gargles 241 

Care of the Teeth 244 

Pyorrhea Alveolaris 246 

The Examination of Stomach Contents 247 

Examination of Feces 252 

Interpretation of Symptoms Referable to the Stomach 257 

Acute Dysentery 261 

Gastric and Duodenal Ulcer 267 

Intestinal Stasis 274 

Spastic Constipation 277 

Hyperacidity 281 

Tapeworm 285 

Ascaris Lumbricoides : Round Worm 287 

Oxyuris Vermicularis : Pin Worm 288 

Diseases of the Kidney 290 

Pyelitis 290 

Acute Nephritis 294 

Chronic Nephritis 298 

Uremia 302 

Cystinuria 303 

Diseases of Metabolism 305 

Diabetes Mellitus 305 

Diabetes Insipidus 310 

Obesity 311 



CONTENTS 9 

PAGE 

Disturbance of the Heart 316 

Acute Pericarditis 317 

Myocardial Disturbances 320 

Endocarditis 323 

Acute Mild Endocarditis 323 

Malignant (Ulcerative) Endocarditis 325 

Chronic Endocarditis 327 

Acute Heart Attack 336 

Broken Compensation 337 

Angina Pectoris 341 

Auricular Fibrillation 343 

Heart Block 346 

Disturbances of the Blood and Blood-Making Organs 348 

Anemia 348 

Pernicious Anemia 351 

Leukemia 353 

Hodgkin's Disease 356 

Disturbances of the Thyroid 358 

Hyperthyroidism 358 

Simple Struma of the Thyroid 364 

Hypothyroidism (Hyposecretion) 365 

Diseases of the Nervous System 375 

Chorea 375 

Epilepsy 377 

Headaches 381 

Sciatica 388 

Backache 395 

Intoxications 399 

Treatment of Drug Addictions 399 

Lead-Poisoning 406 

Delirium Tremens 409 

Illuminating Gas Poisoning 413 

Heat Prostration and Sunstroke 415 

Asphyxia 420 

Diseases of the Eye 424 

Ophthalmia Neonatorum 424 

Blepharitis 425 

Hordeolum : Stye 427 

Iritis 428 

Burns of the Eye from Lime 431 



10 CONTENTS 

PAGE 

Diseases of the Ear 433 

Otitis Media 433 

Solutions for Use in the Ears 435 

Diseases of the Skin 436 

Pruritus : Itching 436 

Pruritus Ani 442 

Pruritus Vulvae 446 

Scabies 446 

Ringworm : Tinea Trichophytina 448 

Tinea Tonsurans 452 

Tinea Cruris 454 

Impetigo Contagiosa 456 

Psoriasis 457 

Boils ( Furuncles ) 460 

Alopecia : Baldness 461 

Urticaria 471 

Roentgen Dermatitis 473 

Hyperkeratotic Eczema of Palms and Soles 474 

Chapped Hands 477 

Chilblain 478 

Frostbite 480 

Lichen Planus 482 

Vaccine Therapy in Skin Diseases 484 

Boric Acid in Skin Diseases 486 

Picric Acid in Skin Diseases 490 

Treatment of Perspiring Feet 492 

Burns 492 

Diseases of the Genito-Urinary Tract 494 

Acute Gonorrhea 495 

Prostatitis and Seminal Vesiculitis 503 

Chronic Hypertrophy of the Prostate 507 

Obstetrics and Gynecology 515 

Toxemias of Pregnane} 515 

Vomiting of Pregnancy 517 

Eclampsia 521 

Puerperal Infection 524 

Postpartum Hemorrhage 534 

Uterine Hemorrhage 535 

Dysmenorrhea 541 

Sterility in Women 544 

\sphyxia Neonatorum 546 



CONTENTS 11 

PAGE 

Diseases in Infancy 552 

Infant Mortality and Feeding 552 

Infantile Convulsions 561 

Incontinence of Urine in Children 563 

Physical Therapy 566 

The Local Application of Dry Hot Air 566 

Hydrotherapy 571 

Gruels and Starchy Drinks 575 

Albuminous Drinks 580 

Miscellaneous 582 

Anesthesia 582 

Disinfection 588 

Anaphylaxis — (Allergy) 593 

Useful Drugs 605 

Calcium 605 

Lecithin : Egg- Yolk 616 

Ichthyol 619 

Hypnotics 620 

Bromids 620 

Chloral 624 

Paraldehyd 628 

Sulphonal 630 

Trional 632 

Scopolamin , 633 

Circulatory Depressants . . 637 

Magnesium Oxid ■ 640 

Cathartics 642 

Cascara Sagrada 645 

Podophyllum or Mayapple 646 

Aloes 648 

Rheum— Rhubarb 650 

Jalap 652 

Croton Oil 654 

Elaterin 655 

Salicylic Acid 657 

Index 663 



PRESCRIPTION WRITING 



INTRODUCTION 

Correct prescription writing is such a close corollary 
to good therapeutics that it seems pertinent to introduce 
it in this book. Although some of the material which 
appears in this and subsequent chapters may seem ele- 
mentary, it is hoped that the physician who cares to 
read it will pardon such detail in order that the sub- 
ject may be presented entire. 

Therapeutics in its broadest sense is the ultimate aim 
of the science and practice of medicine. It includes 
not only drug therapy, to which its definition is so 
often erroneously limited, but also everything that has 
to do with the treatment of the disease, the manage- 
ment of the patient, his convalescence, or his perma- 
nent return to health, and of the prevention of disease 
attacking the well. 

The administration of drugs is only a small part of 
the management of disease, and the management of 
disease is the highest pinnacle of the medical curricu- 
lum. It presupposes all the physiologic, chemical, 
anatomic, pathologic, bacteriologic and pharmacologic 
knowledge that can be obtained. This knowledge is 
then brought to bear on the management of the dis- 
ease, which means necessary hygienic changes, perhaps 
a change of climate, an arrangement of the food and 
drink, physical treatment if indicated, such mental 
treatment as is advisable, such medicinal treatment as 
is needed, and necessary operative procedures, and, 
altogether this is therapeutics. The subject of thera- 
peutics is, then, the broadest and the hardest one for 
the medical student to grasp, and it is safe to say that 
the young graduate in medicine, even after a hospital 
course, is less prepared in the bedside and office man- 
agement of disease than in any other branch of his art. 

A proper understanding of and proper teaching of 
the ability of the mind to overcome many nervous 
disorders, to prevent the misinterpretation of, and the 
exaggeration of, slight physical disturbances should 



14 WHAT TO PRESCRIBE 

be encouraged. Psychotherapeutic instruction should 
be given in every medical school, and hospitals should 
have psychotherapeutic wards. 

PRESCRIBING PROPRIETARIES 

While simplicity in prescription-writing is advisable, 
it cannot be gainsaid that the art of combining drugs 
or of rendering a drug less disagreeable should be 
taught in the medical schools. Even with this laudable 
object in view, however, it is not justifiable for a 
physician to belittle his profession and forget rational- 
ity in his treatment of a patient, to say nothing of 
the enormous graft which he hands the proprietary 
firms from the pockets of his patients, by ordering 
proprietary mixtures. The physician who orders such 
preparations does not realize the positive harm he 
often does his patients, in some instances almost 
amounting to criminal negligence. No one deems it 
reputable, or scientific, or just to patients to prescribe 
preparations the ingredients of which he does not 
know. This is little less than malpractice. With the 
aid of an honest druggist, by means of our Pharma- 
copeia and National Formulary, we hardly need a 
single proprietary mixture in the medicinal treatment 
of disease. 

PHARMACOPEIA AND NATIONAL FORMULARY 

Few physicians know the range and compass of these 
books. No sane person would advocate using all of 
the heterogeneous mass of preparations included in 
them, but every physician can, with the aid of his drug- 
gist, select the few formulas that he will use that will 
be as elegant and pleasant methods of giving drugs 
as proprietary preparations, and, moreover, will repre- 
sent guaranteed doses of the various ingredients of the 
formulas selected. While the use of some of the 
ready made preparations is advised, it should be under- 
stood that it is much better to combine one's own 
prescription to fit the individual case. 

None of this should prevent a physician from trying 
a new drug if he thinks it is an honest one, because 
we should be ever ready to make use of a valuable dis- 
covery, but never to further fraud. Such a new drug 
should be ordered straight or used only in our own 



OFFICIAL PREPARATIONS 15 

combinations, and never in a ready-made mixture 
offered by the firm interested. New and Nonofficial 
Remedies is a book containing a list of such approved 
remedies, with a description of their preparation, their 
action and dosage. 

OFFICIAL PREPARATIONS 

The principal preparations of the United States 
Pharmacopeia may be classified as follows : 

1. Solids mostly for internal use : 

A. Extracts (extracta). 

B. Pills (pilulae). 

C. Powders (pulveres). 

2. Liquids mostly for internal use : 

A. Waters (aquae). 

B. Elixirs (elixira). 

C. Emulsions (emulsa). 

D. Fluidextracts (fluidextracta). 

E. Infusions (infusa). 

F. Liquors (liquores). 

G. Mixtures (misturse). 
H. Spirits (spiritus). 

I. Syrups (syrupi). 

J. Tinctures (tincturae). 

3. Semisolids for external use : 

A. Cerates (cerata). 

B. Ointments (unguenta). 

4. Liquids for external use : 

A. Liniments (linimenta). 

B. Some waters (aquae). 

C. Some liquors (liquores). 

D. Some tinctures (tincturae). 

i. Solids Mostly for Internal Use 

A. Extracts are concentrated preparations of a drug, 
and are mostly moist and sticky. A few extracts are 
dry. They should be prescribed in pill or capsule. 

The most important are : 

Extractum belladonnae foliorum Dose, 0.01 gm. or gr. 1/6 

Extractum digitalis Dose, 0.01 gm. or gr. 1/6 

Extractum ergotae Dose, 0.25 gm. or gr. iv 

Extractum nucis vomicae Dose, 0.01 gm. or gr. 1/6 

Extractum physostigmatis Dose, 0.01 gm. or gr. 1/6 

Extractum rhamni purshianae Dose, 0.25 gm. or gr. iv 

Extractum opii Dose, 0.03 gm. or gr. 1/2 



16 OFFICIAL PREPARATIONS 

B. Official pills are ready-made preparations, and 
consequently it should be remembered that they may 
have deteriorated or become more or less insoluble. 
Still some of the laxative pills, especially, are of value. 

The following is a ready reference to the ingredients 
of the most used pills : 

BlaucTs pills (pilulse ferri carbonatis) contain 0.065 gm. 

(1 gr.) of iron. 
Pills of aloes (pilulse aloes) contain 0.13 gm. (2 gr.) of 

aloes. 
Pills of aloes and iron (pilulse aloes et ferri) contain 0.065 

gm. (1 gr.) each of aloes and iron. 
Compound cathartic pills (pilulse catharticse compositse) 

contain extract of colocynth comp. 0.08 gm. (1% gr.) ; 

calomel 0.06 gm. (1 gr.) ; resin of jalap 0.02 gm. 

iYz gr.) ; gamboge 0.015 gm. (% gr.). 
Vegetable cathartic pills (pilulse catharticse vegetabiles) 

contain extract of colocynth comp. 0.06 gm. (1 gr.) ; 

extract of hyoscyamus 0.03 gm. { J / 2 gr.) ; resin of jalap 

0.02 gm. (Yz gr.) ; extract of leptandra 0.015 gm. (% g r «) \ 

resin of podophyllum 0.015 gm. (% gr.). 
Compound laxative pills (pilulse laxativse compositse) con- 
tain aloin 0.013 gm. (1/5 gr.) ; strychnin 0.0005 gm. 

(1/120 gr.) ; extract of belladonna leaves 0.008 gm. (^ 

gr.) ; ipecac 0.004 gm. (1/15 gr.). 
Compound podophyllum pills (pilulse podophylli, belladonnse 

et capsici) contain resin of podophyllum 0.016 gm. (*4 

gr.) ; extract of belladonna leaves 0.008 gm. (y$ gr.) ; 

capsicum 0.032 gm. (yi gr.). 
Compound rhubarb pills (pilulse rhei compositse) contain 

rhubarb 0.13 gm. (2 gr.) ; aloes 0.10 gm. (1^2 gr.) ; 

myrrh 0.06 gm. (1 gr.). 

C. Official powders are dry preparations of two or 
more drugs. It is better to order a powder by its 
official title, but below are the common names and the 
ingredients of the most used of these preparations : 

Dover's powder (pulvis ipecacuanhse et opii) contains 10 
per cent, each of ipecac and opium. 

Tully's powder (pulvis morphinse compositus) contains 1.5 
per cent, of morphin and 32 per cent, of camphor. 

Compound aromatic powder (pulvis aromaticus) is a mix- 
ture of aromatics. 

Compound jalap powder (pulvis jalapse compositus) con- 
tains 35 per cent, of jalap and 65 per cent, of potassium 
bitartrate. 

Compound licorice powder (pulvis glycyrrhizse compositus) 
contains 18 per cent, of senna; 23 per cent, of glycyrrhiza ; 
8 per cent, of sulphur. 



OFFICIAL PREPARATIONS 17 

Gregory's powder, compound rhubarb powder (pulvis rhei 
compositus) contains 25 per cent, of rhubarb; 65 per cent, 
of magnesium oxid; 10 per cent, of ginger. _ 

Seidlitz powder (pulvis effervescens compositus) consists 
of two powders ; one of Rochelle salt and bicarbonate of 
soda in blue paper, and the other of tartaric acid in 
white paper. 

2. Liquids Mostly for Internal Use 

A. Waters are solutions of volatile substances in 
water; mostly weak preparations. (Exception, ammo- 
nia waters.) 

H. Spirits are solutions of volatile substances in 
alcohol; mostly strong preparations. (Exception, 
sweet spirits of niter.) 

F. Liquors are solutions of non-volatile substances 
in water; mostly weak preparations. (Exceptions, the 
arsenic solutions and those for external use.) 

J. Tinctures are solutions of non-volatile substances 
in alcohol; mostly strong preparations. (Exceptions 
are the aromatic and stomachic [bitter] drug tinc- 
tures.) 

H. Some of the common names of spirits are : 

Whisky (spiritus frumenti). 

Brandy (spiritus vini gallici). 

Sweet spirits of niter (spiritus setheris nitrosi). 

F. So'me of the common names of liquors are : 

Fowler's solution (liquor potassii arsenitis). 
Spirit of Mindererus (liquor ammonii acetatis). 
Lugol's solution (liquor iodi compositus). 
Goulard's solution (liquor plumbi subacetatis). 
Labarraque's solution (liquor sodse chlorinatse). 

B. Elixirs are sweetened liquid preparations con- 
taining alcohol. They are weak preparations, and the 
National Formulary contains a large number. 

C. Emulsions are liquid preparations containing a 
suspended oil or resin. 

D. Fluidextracts are liquids representing exact 
strengths of the drugs, i. e., 1 cubic centimeter (IS 
minims) contains the medicinal properties of 1 gram 
(15 grains) of the drug. 



18 SYNONYMS 

E. Infusions are weak watery preparations. One 
only is of value, viz., infusum digitalis. 

G. Mixtures are liquids containing more than one 
drug, often an insoluble one. The most used are: 

Brown mixture (mistura glycyrrhizse compositus). 
Chalk mixture (mistura cretae). 

The National Formulary contains a long list of mix- 
tures. 

I. Syrups are very sweet watery solutions of one or 
more drugs. These weak preparations are prescribed 
too frequently, as they readily cause disturbance of 
the stomach, and do not often modify a bad-tasting 
drug, but may even protract the taste. Sweet cough 
syrups are an abomination. 

3. Semisolids for External Use 

A. and B. The principal difference between cerates 
and ointments is their melting-points. The ointments 
contain more lard or petroleum fat and less wax than 
the cerates, hence they have a lower melting point 
than the latter. Cerates do not melt when applied to 
the skin. 

4. Liquids for External Use 

Some waters, some liquors, some tinctures and the 
liniments, as the name implies, are used externally 
only. Most of the liniments are stimulating to the 
skin, but two being sedative, viz., the belladonna lini- 
ment and the carron oil (linimentum calcis). 

SYNONYMS 

The following are frequently used synonyms : 
Aqua Fort is, Acidum nitricum, U. S. P. 
Aqua Regia, Acidum nitrohydrochloricum, U. S. P. 
Basiiam's Mixture, Liquor ferri et ammonii acetatis, U. S. P. 
Basilicon Ointment. Ceratum resirne, U. S. P. 
Black Draught, Infusum senna.' compositum, U. S. P. 
Black Drop, Acetum opii, U. S. P. 
Black Wash, Lotio nigra, N. F. 
Blaud's Pill, Pilula ferri carbonatis, U. S. P. 
Bleaching Powder, Calx chlorinata, U. S. P. 
Blue Mass, Massa hydrargyri, U. S. P. 
Blue Ointment, Unguentum hydrargyri dilutum, U. S. P. 
Blue Vitriol, Cupri sulphas, U. S. I'. 

Brown Mixture, Mistura glycyrrhizrc composita, U. S. P. 
Carron On., Linimentum calcis, I'. S. P. 
Dobell's Solution, Liquor sodii boratis compositus, N. V. 
Donovan's Solution, Liquor arseni et hydrargyri iodidi, U. S. P. 
Dover's Powder, I'ulvis ipecacuanha et opii, U. S. P. 



THERMOMETRY EQUIVALENTS 19 

Epsom Salts, Magnesii sulphas, U. S. P. 
Fowler's Solution, Liquor potassi arsenitis, U. S. P. 
Glauber Salt, Sodii sulphas, U. S. P. 
Goulard's Extract, Liquor plumbi subacetatis, U. S. P. 
Gray Powder, Hydrargyrum cum crete, U. S. P. 
Gregory's Powder, Pulvis rhei compositus, U. S. P. 
Griffith's Mixture, Mistura ferri composita, U. S. P. 
Hive Syrup, Syrupus scillae compositus, U. S. P. 
Hoffmann's Anodyne, Spiritus <etheris compositus, U. S. P. 
Huxham's Tincture, Tinctura cinchonae composita, U. S. P. 
Labarraque's Solution, Liquor soda? chlorinatse, U. S. P. 
Lugol's Solution, Liquor iodi compositus, L T . S. P. 
Lunar Caustic, Argenti nitras fusus, U. S. P. 
Magendie's Solution, Liquor morphinae hypodermicus, N. F. 
Monsell's Solution, Liquor ferri subsulphatis, U. S. P. 
Sugar of Lead, Plumbi acetatis, U. S. P. 
Vallet's Mass, Massa ferri carbonatis, U. S. P. 
Warburg's Pill, Pilula antiperiodica, N. F. 
Warburg's Tincture, Tinctura antiperiodica, N. F. 
Yellow Wash, Lotio flava, N. F. 

THERMOMETRIC EQUIVALENTS 

To convert degrees Centigrade to degrees Fahrenheit, 
multiply by 9, divide by 5, and add 32 to the quotient. To 
convert degrees Fahrenheit to degrees Centigrade, substract 
32, multiply by 5 and divide by 9. A few commonly used 
equivalents are as follows : 

Freezing point of water. 
Greatest density of water. 
Temperature at which most hygrom- 
eters are graduated. 
Used in estimations as room tempera- 
ture. 
Normal body temperature. 

Point of inactivation. 
Sterilizing and Pasteurizing tempera- 
ture. 
100 = 212 Boiling point. 

WEIGHTS AND MEASURES 
It is not necessary to describe here the old system 
or to give its tables of weights and measures, as they 
occur in every book on prescription-writing, but some 
tables of approximate equivalents to the metric sys- 
tem will be offered. Exact equivalent tables are a 
delusion and only tend to befog and discredit the 
metric system. When it is remembered how the doses 
of drugs vary, it will be recognized how absurd it is 
to figure an equivalent to its finer determinations. 

It is not necessary to declare that the decimal 
(metric) system of prescription-writing is the better, 
because the fact is recognized by all and the only hin- 
drance to its use is the supposed difficulty of mastering 



c. 


F. 


= 


+ 32 


4 = 


40 


15.5 = 


60 


25 = 


77 


37 = 


98.6 


40 = 


104 


56 = 


132.8 


60 = 


140 



20 WEIGHTS AND MEASURES 

it. Science of all countries has adopted it — even our 
own Pharmacopeia. If the novice in the use of the 
metric system in prescription-writing will remember 
that it is a decimal system like our monetary system, 
that everything on the left of the decimal point or line 
represents grams or cubic centimeters [dollars], that 
everything on the right of the decimal line represents 
centigrams, milligrams, or fractions of a cubic centi- 
meter [cents and mills], he will soon understand the 
system. A rule for the approximate conversion of 
apothecary dosage into metric is to write for a two 
ounce mixture as many grams as there would be grains 
in a single dram dose. 

In this country it is customary in writing prescrip- 
tions in the metric system to write for solids in terms 
of grams and fractions of grams, and for liquids in 
terms of cubic centimeters or fractions of cubic centi- 
meters. The same decimal line which should be ruled 
on the prescription blank answers for both solid and 
liquid metric measures, and precludes all possibility 
of careless decimal mistakes, as : 

• gra- 
ce. 



It is best to use in prescribing, only two denomina- 
tions, grams and milligrams. Liquids, of course, are 
expressed as cubic centimeters. 

As above declared, it is useless to translate the old 
system into exact equivalents of the new system. One 
must compute the doses in the new system; one must 
forget the size of stock bottles and order amounts of 
liquids in multiples of five, as 15 c.c, 25 c.c, 50 c.c, 
100 c.c, or 200 c.c. ; one must remember that 5 c.c. is 
a teaspoonful dose, i. c, an ordinary teaspoon holds 
5 c.c and not 4 c.c or a liquid dram ; in other words, 
every prescriber in the old system has always given a 
larger dose than he intended when he computed the 
dose by fluidrams and then administered a teaspoon- 
ful ; one should remember that the drop, so much used 
in prescribing strong liquid preparations, is as correct in 
the new system as in the old. All of these suggestions 



WEIGHTS AND MEASURES 21 

must be followed out to use the metric system suc- 
cessfully. 

TABLE OF THE APPROXIMATE EQUIVALENTS ON THE TWO SYSTEMS 

gm. 
c.c. 
1 grain -(gr.i) = approximately... 0|065 = 65 milligrams 

= 1 grain. 
1 minim (rrti) = approximately... 0|065 = 65/1000 of a 

cubic centime- 
ter = 1 minim. 

15 grains (gr.xv) = approximately. 1| =1 gram = 15 

grains. 
15 minims (n\xv) = approximately. 1| =1 cubic centi- 
meter — 15 
minims. 

1 dram (3i) = approximately 4| =4 grams == 1 

dram. 

1 fluidram (fl.Si) = approximately. 4| == 4 cubic centi- 
meters = 1 
fluidram. 

1 ounce (Si) = approximately 30 1 = 30 grams — 1 

ounce. 

1 fluidounce (fl.Si) =approximately.30| = 30 cubic centi- 
meters = 1 
fluidounce. 

1 quart = approximately 1000 c.c, or 1 liter. 

1 pint = approximately 500 c.c. 

1 teaspoonful == approximately 5 c.c. 

It is always a good plan to use a stub prescription 
blank, and on the stub the individual doses may be 
written. This is another check on mistakes and also 
preserves for reference the exact dose given on the 
exact date, as : 

Stub (one dose) Prescription for 20 doses 

gm. Old 

I£ I£ c.c. system 

Strych. sulph. 001 Strychninse sulphatis.. |02 gr.H 

Ferri reducti. 05 Ferri reducti 1| or gr.xv 

Quin. sulph.. 10 Quininse sulphatis 2| gr.xxx 

M. et F. cap. M. et F. capsulas 20. 

Sig. : t.i.d., p.c. Sig. : A capsule 3 times a day, after 

Name. meals. 

Age. 

Date. 



22 INCOMPATIBILITY 

Or, 

Stub (one dose) Prescription for 20 doses 

gm. Old 

B I> c.c. system 

(approximately) 
Codein. sulph.. .01 Codeinse sulphatis.. 20 gr.iv 

Ammon. chlor. .25 Ammonii chloridi.. 5 3iss 

Syr. acid. cit.. 1.25 Syrupi acidi citrici. 25 fLSi 

Aquam ad 5. Aquam ad 100 ad fljiv 

M. M. 

Sig. : 5 c.c.q. 2 h. Sig. : A teaspoonful, in water, every 
in H 2 0. two hours. 

Shake. 

It is well to use the Arabic numerals instead of the 
Roman in the new system, as : 

Pilulas rhei compositas No. 20. 
Sig. : One pill after supper. 

Stub (single dose) Prescription 

gm. Old 

I£ I£ c.c. system 

Tr. digitalis. Tincturse digitalis... 25j or fl.Si 

Sig. : 10 drops in Sig. : Ten drops, in water, twice a day, 
H 2 b.i.d., p.c. after meals. 

Stub Prescription 

gm. Old 

I£ I£ c.c. system 

Ung. hg. ammon. LJnguenti hydrargyri or 

Petrolati . ...aa 10 ammoniati 10J aa 3iiss 

M. Petrolati 10| 

Sig. : Externally. M. 

Sig. : Use externally as directed. 

INCOMPATIBILITY 
This is prevented only by great care and simplicity. 
Too many drugs should not be prescribed. Too many 
solutions should not be combined. Too many drugs 
and too much medicine should not be given to one 
patient on any one or two days. Many drugs are 
cumulative and many of their physiologic activities 
are antagonistic. Drugs may be incompatible therapeu- 
tically, chemically and pharmaceutically. 

Therapeutic incompatibility occurs when drugs are com- 
bined which have antagonistic physiologic actions. 



INCOMPATIBILITY 23 

Chemical incompatibility occurs when from the combination 
of two or more drugs a new and undesired chemical com- 
pound results. 

Pharmaceutic incompatibility occurs when drugs are com- 
bined which form, either immediately or later, cloudy, pre- 
cipitated or decomposed solutions. 

An educated physician should be ashamed to perpe- 
trate a therapeutic incompatibility either in a prescrip- 
tion or in a patient. It is not therapeutic incompati- 
bility, however, to modify a too decided action of a 
drug with one that corrects an undesired effect. This 
is a part of therapeutic science. 

Pharmaceutical incompatibility is so closely related 
to chemical incompatibility that many times both are 
governed by the same rule. Such incompatibility is 
difficult to avoid, and therefore it is advisable to adopt 
simplicity in prescription- writing ; this is really a thera- 
peutic gain. 

Below is given an alphabetical list of drugs compris- 
ing those that should generally be given alone, 
especially in solutions. The chemical reasons are 
appended : 

Acids, unless very dilute and in small amount, should be 
prescribed alone. They combine with bases to form salts, and 
are incompatible with oxids, alkalies, alkaline salts, hydrates 
and carbonates. They usually precipitate albumin. 

Alkalies and alkaline carbonates should rarely be prescribed 
in solution with other drugs. The}' form salts with acids and 
precipitate many metallic and alkaloidal salts. 

Alkaloidal salts should rarely be combined with other drugs 
in solutions. They are precipitated by alkalies, alkaline car- 
bonates, earthy carbonates, preparations containing tannic 
acid, and by iodids in solution. 

Antimony and potassium tartrate (tartar emetic) should 
be prescribed in solutions alone. It is incompatible with acids, 
alkalies, tannic acid, and preparations containing tannic acid. 

Arsenic (arseni trioxidum, arsenious acid) should gener- 
ally be prescribed in solutions alone. 

It is precipitated by salts of iron, magnesia, and solutions 
of lime. 

Bromids in solution should not be combined with alkaloids. 
They precipitate the salts of morphin, quinin, and strychnin 
from neutral solutions. 



24 THE HARRISON ANTINARCOTIC LAW 

Ferric and ferrous salts should generally be prescribed 
alone. They are incompatible with tannic acid and all drugs 
containing it; with alkaline carbonates, ammonia, and acacia. 

Iodids should generally be prescribed alone. 

They are incompatible with salts of alkaloids and metals 
and with mineral acids. 

Mercuric chlorid (corrosive sublimate) should generally be 
prescribed alone. It is incompatible with many drugs. 

Mercurous chlorid (calomel), though insoluble, had best 
not be prescribed in mixtures. In solutions containing 
chlorids it may be converted into the mercuric salt. 

Resins, including oleoresins, and fluidextracts and tinctures 
containing resins, should not be prescribed in watery solu- 
tions, though they may be ordered in emulsion by suspending 
them with the mucilage of acacia or tragacanth. 

They are all precipitated by water. 

Silver nitrate solutions and solutions of all silver salts 
must be ordered alone, and kept in dark bottles. If silver 
salts are prescribed for internal administration they must be 
alone or combined with some earth, and given in capsules. 

Strophanthus in the form of the tincture should not be 
prescribed in solutions containing water. 

Spirits (spiritus), except sweet spirits of niter, whisky 
and brandy, should mostly not be prescribed with watery 
preparations. They become cloudy on the addition of water. 

Tannic acid, and all drugs containing tannic acid, should 
not be prescribed with most drugs. They are incompatible 
with alkaloids, salts of iron, lead, silver and antimony. 

THE HARRISON ANTINARCOTIC LAW 

This law affects the physician both as a prescriber 
and as a dispenser of drugs. It requires the pre- 
scribing physician to register with the collector of 
internal revenue of the district. In writing a prescrip- 
tion for narcotic or habit forming drugs, coming under 
this act, the physician must write thereon the name 
and address of the patient, and must have on the pre- 
scription his office address and his registry number. 
He must sign his name in full. He need not keep 
either copies or records of prescriptions ; this is done 
by the druggist. These prescriptions cannot be refilled. 

If the physician desires any of the specified drugs 
for his own use, he must then make out an order for 
them on a blank form bearing his registry number. 
These blanks are furnished by the Internal Revenue 



LATIN 25 

Department in packages of ten for ten cents. The 
physician cannot order drugs for his own use on a 
prescription blank. 

When he dispenses, the physician assumes the work 
of the druggist and is subject to the same rules. He 
must then keep a record in a suitable book of all habit- 
forming drugs dispensed, the number of persons dis- 
pensed to and the date. Such treatments as he may 
personally administer, or cause to be administered 
when away from his office need not be recorded. 

LATIN 

Enough has been said in the introduction concern- 
ing the desirability of writing prescriptions for Phar- 
macopeial or National Formulary preparations. The 
corollary to this advice is to write a prescription cor- 
rectly, as to dosage, compatibility and Latin. It is 
presumed that the groundwork of prescription-writing 
has been acquired from some elementary book, and it 
is proposed here merely to furnish some hints which 
may be an aid in writing prescriptions simply, cor- 
rectly and elegantly, and in preventing some of the 
more serious mistakes in Latin. 

The beginning of a prescription is usually the letter 
1^, meaning recipe ("take," imperative mood of the 
verb recipio) ; the cross over the tail of the ^, it has 
been said, is an abbreviated zodiacal sign or invocation 
to Jupiter. Others have claimed it is simply an abbre- 
viation. This verb recipe takes the quantities of the 
drugs ordered in the accusative, while the names of the 
drugs are in the genitive case, as : 



impe 


rative verb 


genitive case 


accusative case 


take 




of soda 


1 gram (or 15 grains) 


n 




sodii bicarbonatis 


1 gm. or gr.xv 



In the following lists of words and rules for the 
correct use of Latin in prescriptions, Osborne's 
"Introduction to Materia Medica and Pharmacology" 
has been freely drawn on. 

Rules for Cases in Prescriptions 

1. The verbs fac and recipe (I£) take objects in the 
accusative case. 



26 LATIN 

2. When the object of the verb is the quantity 
ordered, the name of the medicine goes in the geni- 
tive case. 

3. In the following instance, the name of the sub- 
stance goes in the accusative case, as the object of the 
verb. The quantity is given in a dependent phrase 
(ad 30 c.c), and therefore cannot be the object. 



B 


Aquam 


ad 30 c.c. or fl.Si 


Take 


water 


up to 30 c.c. or 1 fluidounce 



But the name of the substance goes in the genitive 
in the following instance : 

fy Aquas q.s. ad 30 c.c. or fl.Si 

Take of water as much as up to 30 c.c. or 1 fluidounce 
necessary 

Here the object of recipe is q. s., on which aquae 
depends. 

The Declension of Pharmacopeial Latin Nouns 

With few exceptions nouns ending in — a have the 
genitive ending in — ae; nouns ending in — um and 
— us have the genitive ending in — i ; all others in — is. 

Exceptions 

The various exceptions to the above rule may be 
found by consulting the above-mentioned manual of 
prescription-writing. As indication of the changes in 
irregular forms the following may be mentioned : 

NOMINATIVE GENITIVE 

theobroma theobromatis 

spiritus spiritus 

rhus rhou 

pix picis 

folia (ol.) i'oiiorum 

Abbreviations Used in Prescription-Writing 

It is common to use certain abbreviations in pre- 
scription writing. This is perhaps due to the fact that 
abbreviations dispense with the need of remembering 
the various endings. The Pharmacopeias have recog- 
nized official abbreviations of pharmacopeial titles. The 
following arc abbreviations of Latin phrases com- 
monly used in directions : 





DOSAGE 


27 


Abbreviation 


Latin 


Translation 


aa 


ana (Greek) 


of each 


ad 


ad 


up to 


ad lib. 


ad libitum 


to the desired amount 


cap. 


capsula, — ae. 


a capsule 


co. or comp. 


compositus-a-um 


compound 


div. 


divide 


divide 


ext. 


extractum, — i 


an extract 


ft. 


fiat or fiant 


let it (or them) be made 


next. 


nuidextractum, — i, 


a fluid extract 


gtt. 


gutta, — ae 


drop or drops 


liq. 


liquor, — is. 


a solution 


m. 


misce 


mix 


mist. 


mistura, — ae 


a mixture 


pil. 


pilula, — ae 


a pill 


pulv. 


pulvis, — eris 


a powder 


q. s. 


quantum sufficiat 


a sufficient quantity 


ss. 


semis, semissis 


a half 


sig. 


signa 


mark 


sol. 


solutio, — onis 


a solution 


spts. 


spiritus 


a spirit 


t. i. d. 


ter in die 


three times a day 


tr. 


tinctura, — ae 

Latin Verbs 


a tincture 



The Latin verbs used are best placed in the impera- 
tive mood. The most frequently used are: 



adde (add) 
divide (divide) 
fac (make) 
filtra (filter) 



misce (mix) 
recipe (take) 
signa (write) 
solve (dissolve) 



DOSAGE 

The dose of a drug should be based on the age, 
weight and individuality of the patient, and the neces- 
sity for a strong action of the drug. 

The frequency of the dose is determined by the 
results obtained, by the length of time it takes the drug- 
to be eliminated or cease its action, and the possibility 
of its causing a cumulative effect. 

While age is an all-important element in the deter- 
mination of the dose, the weight, unless in the obese, 
is the most important element, except in the case of 
narcotics given to children. Children have more cen- 
tral nervous system as compared to their weight than 
adults, and therefore are more profoundly affected by 
drugs which act on the brain, than are adults. In 
other words, a given dose of a narcotic, especially of 
the opium series, for an adult must be more reduced 
in size for a young child than any table of reduction 
computed by age or weight would determine. 



28 AVERAGE WEIGHT AND HEIGHT 

The best simple rule of dosage by age is the fol- 
lowing : 

At 20 years, the adult dose. 
At 10 years, Yz the age, y 2 the dose. 
At 5 years, % the age, % the dose. 
At 2]/ 2 years, Y% the age, % the dose. 
At 1 year, %2 the dose. 

Children whose ages are between the ones here 
specified may readily be prescribed doses a litle more 
or less than the dose determined by the age nearest 
theirs in the table. 

The relation of size and weight to the dose is all- 
important. A large child of 2 years should certainly 
receive a larger dose than a weakly, small child of the 
same age. Also a small adult of 20 should receive less 
than a large muscular individual of the same age. The 
blood of an adult represents about one-thirteenth of 
his total weight. This is not true of children or of the 
obese. Hence the dose of an obese individual may be 
even less than if his weight were normal. 

The following are the average weights for normal 
adult males. It should be remembered that females 
up to the age of 45 or 50 generally weigh less than 
males ; also that a range of from 20 to 25 pounds above 
or below the average weight, the patient's general con- 
dition being good, is not necessarily considered a 
weight too high or too low for acceptance as an insur- 
ance risk. Above or below this range of 20 to 25 
pounds from the average is generally considered over- 
weight or under-weight, and the acceptance of such 
an individual for insurance becomes questionable. 

TABLE OF AVERAGE WEIGHT TO HEIGHT AT DIFFERENT 

AGES 



Ft. In. 


15-24 


25-29 


30-34 


35-39 


40-44 


45-49 


50-54 


55-60 


5-0 


120 


125 


128 


131 


133 


134 


134 


134 


5-1 


122 


126 


129 


131 


134 


136 


136 


136 


5-2 


124 


128 


131 


133 


136 


138 


138 


138 


5-3 


127 


131 


134 


136 


139 


141 


141 


141 


5-4 


131 


135 


138 


140 


143 


144 


145 


145 


5-5 


134 


138 


141 


143 


146 


147 


149 


149 


5-6 


138 


142 


145 


147 


150 


151 


153 


153 


5-7 


142 


147 


150 


152 


155 


156 


158 


158 


5-8 


146 


151 


154 


157 


160 


161 


163 


163 


5-9 


150 


155 


159 


162 


165 


166 


167 


168 


5-10 


154 


159 


164 


167 


170 


171 


172 


173 


5-11 


159 


164 


169 


173 


175 


177 


177 


178 


6-0 


165 


170 


175 


179 


180 


183 


182 


183 


6-1 


170 


177 


181 


185 


186 


189 


188 


189 


6-2 


176 


1S4 


188 


192 


194 


196 


194 


194 


6-3 


181 


190 


195 


200 


203 


204 


201 


198 



DOSAGE 29 

In determining the dose it is most important to con- 
sider whether or not the patient has any exceptional 
susceptibility to the given drug. When an idiosyncrasy 
or abnormal susceptibility to a certain drug or to 
drugs of a certain class is known, the drugs causing 
it should, if possible, not be administered. That 
peculiar phenomenon, now known as anaphylaxis, is 
one which also should be taken into account in this 
connection. 

Sometimes such undesired action of a drug occurs 
with the first dose only, notably in the case of quinin, 
and a tolerance to the drug is, after this first dose, 
temporarily acquired. 

Another idiosyncrasy of a patient may represent a 
tolerance to a drug such that large doses must be 
given to produce any effect. This tolerance may 'be 
natural or acquired by previous use of the drug. 

Still other very important predispositions of a patient 
are caused by the disease affecting him, by the condi- 
tion of his digestive and absorptive system, and by the 
condition of his eliminative organs. The disease pres- 
ent may create a tolerance or an increased suscepti- 
bility to a drug. Slow absorptive powers may render 
the action of the drug almost impossible or allow 
accumulation of dangerous amounts of the drug 
(under which conditions the drug should be given 
hypodermatically, if it is needed). Slow or retarded 
elimination due to defective eliminative organs will 
allow cumulative action of many drugs. 

The drugs which are most frequently found unex- 
pectedly to cause undesirable or even serious symptoms 
in susceptible individuals are quinin, salicylates, atro- 
pin-containing drugs, iodin-containing drugs, and 
opium and its alkaloids. 

The diseased conditions that most seriously modify 
(lessen )the dose of a drug are nephritis and cirrhosis 
of the liver. 

A condition of shock precludes immediate absorp- 
tion from the stomach, hence such a condition must 
be combated, if by drugs, hypodermatically. 

Frequency of the Dose 
It should be carefully learned how long, ordinarily, 
it takes a given dose of a drug to act, and how long 



30 DOSAGE 

before it is mostly eliminated. This determines the 
frequency of the dose. Also some drugs are elimi- 
nated so slowly that they tend to accumulate in the 
system or are deposited in the various organs so that 
medication may occur days and even weeks after the 
cessation of the administration of the drug. 
A few of the rapidly acting drugs are: 

Alcohol Iodids 

Ammonia Salicylates 

Camphor Strophanthin 

Cafjfein Strychnin 
Chloral 

These act in a few minutes to an hour or so, hence 
the intervals at which they may be given range from 
every hour to every three hours, or three times a day, 
according to the drug. 

A few of the slowly acting drugs are : 

Arsenic Quinin 

Atropin Synthetic antipyretics 

Bromids Synthetic hypnotics 

Digitalis Thyroid 

Mercury 

These act in from several hours to twenty, hence 
should be given once or twice a day, according to the 
drug. 

A few of the drugs that tend to accumulate in the 
system are: 

Arsenic Digitalis 

Atropin Mercury 

Bromids Strychnin 

Many drugs cause eruption on the skin either due 
to irritation of the stomach and duodenum or to their 
being more or less excreted by the skin and irritating 
the glands during such excretion, or they may cause 
flushing of the skin. 

Examples of drugs causing the first kind of irrita- 
tion are : copaiba, chloral, opium, quinin, salicylates, 
synthetic compounds, volatile oils; drugs of the sec- 
ond type are arsenic, bromids and iodids ; those of the 
third type are antitoxin, atropin and thyroid. 

It should always be remembered that some drugs 
are excreted into the milk; hence if the mother is 



METHODS OF ADMINISTRATION 31 

nursing her baby, some drugs should be avoided, and 
some given only infrequently; or on the other hand, 
the baby may be medicated through the mother. 

Generally speaking, most narcotics (opium, bromids 
etc.) ; most so-called alteratives (arsenic, mercury, 
iodids, thyroid) : most cathartics and quinin are 
excreted by the milk. 

METHODS OF ADMINISTERING DRUGS 
Drugs and serums are more than occasionally admin- 
istered intravenously, but as the technic requires skill, 
most perfect asepsis, and should require the enforce- 
ment of at least twenty-four hours of absolute rest, 
this method is not likely to be frequently resorted to. 
Moreover it seems to be a fact that, when a drug or 
serum is injected intramuscularly, the rate of absorp- 
tion and activity of a substance is almost as rapid as 
when it is given intravenously, and the danger of acci- 
dents is much less. 

The hypodermatic or subcutaneous method is of 
very great value in all emergencies, but should not be 
used too frequently. Of course the most frequent 
need for such medication is caused by pain, which must 
be combated by morphin or its equivalent, and the 
danger of acquiring a habit is greater when the drug 
is used hypodermatically than when it is given in any 
other way. 

Of course the most frequent method of giving a 
drug is by the mouth, either in liquid, powder, pill, 
capsule or tablet. A drug will surely act more quickly 
if given in liquid solution, and more quickly on 
an empty stomach. If it is disagreeable, however, it 
should be given in capsule if the character and 
dose of the drug will allow it. Also if a drug is irri- 
tant, it should not be given on an empty stomach. A 
disagreeable liquid drug should not be combined with 
a syrup, which does nothing but prolong the taste and 
upset the stomach, but should be given in plain water 
to be followed by any kind of taste the patient prefers, 
such as orange, lemon, or by a peppermint or winter- 
green candy for example. Or the liquid may be given 
in a sour mixture as lemonade or syrup of citric acid 
and water, or it may be given in a mineral or car- 



32 METHODS OF ADMINISTRATION 

bonated water. A powder may be given in milk or in 
an effervescing water. 

Capsules are the nicest means of giving drugs dis- 
agreeable in taste and small in dose. The contents of 
a capsule should be dry for rapid solution, the princi- 
pal advantage of a capsule over a pill. If rapid action 
is desired, or if it is feared that the capsule, slowly dis- 
solving on a small part of the mucous membrane of the 
stomach will irritate the membrane, the capsule may 
be uncapped at the moment of swallowing, and the 
result is the same in the stomach as though the drug 
had been taken in powder. Alcohol in any form in the 
stomach will retard the solution of a capsule. Pills 
are not so much used as before the capsule became so 
popular. The solution and absorption of a pill must be 
slow, unless it contains some particles of a substance 
that swells with water, as starch. Sugar, chocolate, 
or gelatin-coated pills and tablets make the solution 
still slower, though in the case of drugs to act on the 
intestine this may be of advantage. 

The much-used tablet, compressed or triturate, 
doubtless renders much medication valueless, and per- 
haps, fortunately, harmless. The speed of solution of 
most tablets on the market is problematical, hence if 
the action of a tablet is immediately desired it should 
be predissolved, or at least crushed by the teeth 
before swallowing. All antipyretic coal-tar tablets 
should be crushed before swallowing and then a good 
drink of water taken with. them. It should not be for- 
gotten that anything that may bite or irritate the mem- 
brane of the mouth will do the same to the mucous 
membrane of the stomach. Hence bromid tablets 
should never be taken undissolved. Potassium chlo- 
rate tablets dissolved in the mouth or swallowed are 
dangerous. Potassium chlorate solutions for the 
mouth and throat are valuable, but there is no justifi- 
cation for ever taking potassium chlorate into the stom- 
ach or into the system. 

A very soluble tablet dissolved and absorbed from 
the mouth will give almost as rapid action as when 
given hypodermatically. 

The rectum absorbs drugs given by means of sup- 
positories or injections nearly and sometimes quite 



CLASSIFICATION OF DRUGS 33 

as rapidly as does the stomach. But sedatives and 
some laxatives only are ever administered by supposi- 
tories for systemic effect. 

A few drugs are given endermically, but except in 
the case of mercury the method is uncertain. 

Mucous membranes may be treated by douching, 
injection, insufflation, and those of the air passages by 
inhalation. Some drugs are absorbed by all of these 
methods, and if poisonous drugs are used, the possi- 
bility of too great an absorption must always be kept 
in remembrance. 

CLASSIFICATION OF DRUGS 

While dictionaries and encyclopedias must be 
arranged alphabetically for ready reference, alpha- 
betical arrangement of drugs for the practicing physi- 
cian is very unsatisfactory. Also, for a practicing 
physician, classification based on chemical constitu- 
ency, pharmacologic peculiarities, or toxic action is 
absolutely of no value. A drug may have a chemical, 
physiologic or toxic activity that is of no value from 
a therapeutic standpoint. The classification always of 
value and always necessary for the practicing physi- 
cian is one based on therapeutic uses. 

The following classification, arranged according to 
therapeutic indications, is copied from Osborne's 
small text-book on "Materia Medica and Pharmacol- 
ogy." While it could not be claimed that this enumera- 
tion of drugs comprises all that are of value, it does 
comprise the best, and any drug that aspires to a 
place in such a classification must show positive physi- 
ologic activity and therapeutic success to prove that it 
should be classed among these, the best drugs. Under 
each heading the drugs are named alphabetically and 
not in the order of their value. 

FIRST DIVISION — FOR LOCAL ACTION 

Class 1. — Drugs used to destroy microorganisms. 

A. To disinfect (drugs too strong to be used on the body). 
For buildings : Formaldehyd, sulphurous acid, steam. 
For clothing: Formaldehyd, heat. For dejecta: Chlori- 
nated lime. 



34 CLASSIFICATION OF DRUGS 

B. To inhibit the growth of bacteria on the body or in one 
of its cavities (antiseptics) : Alcohol, cresol, formal- 
dehyd solution, hydrogen dioxid solution, mercuric 
chlorid, phenol, salicylic acid. 

C. To destroy skin-parasites (parasiticides) : Betanaph- 
thol, chrysarobin, ichthyol, iodin, mercury, pyrogallol, 
resorcin, sulphur, the above antiseptics. 

Class 2. — Drugs used on the skin. 

A. To protect (dressings) : Acetanilid, bismuth prepara- 
tions, boric acid, iodin synthetic powders, lycopodium, 
talcum, zinc oxid, zinc stearate. 

B. To soothe (emollients) : Almond oil, boroglycerid, 
cacao butter, glycerin, olive oil, petroleum oils, wool fat. 

C. To cause hyperemia (mild counter-irritation) : Tinc- 
ture of iodin, B liniments, mustard. 

D. To blister: Cantharides. 

E. To corrode (escharotics) : Chromic acid, glacial acetic 
acid, nitric acid, potassium hydroxid, salicylic acid, silver 
nitrate, trichloracetic acid. 

Class 3. — Drugs used to act on mucous membranes. 

A. To soothe (demulcents) : Albumin water, barley water, 
flaxseed infusion, milk, warm physiologic saline solu- 
tion, slippery elm infusion. 

B. To diminish secretion (astringents) : Alum, bismuth 
salts, weak silver solutions, suprarenal preparations, 
tannic acid, weak zinc solutions. 

C. To stimulate: Copper salts, silver salts, zinc salts. 

Class 4. — Drugs used for local action in the stomach. 

A. To increase the appetite (stomachics) : Cinchona, gen- 
tian, nux vomica, salicin, vegetable bitters. 

B. To aid digestion: Diastase, hydrochloric acid, pan- 
creatin, pepsin. 

C. To reduce acidity (antacids) : Ammonia, chalk, lime 
water, magnesia, sodium bicarbonate. 

D. To cause vomiting (emetics) : Apomorphin (acting on 
the vomiting center), copper sulphate, ipecac, mustard, 
zinc sulphate. 

Class 5. — Drugs used for local action in the intestinal canal. 

A. To increase peristalsis (carminatives) : Anise, capsicum, 
cardamom, cinnamon, peppermint. 



CLASSIFICATION OF DRUGS 



35 



B. To promote evacuation of the bowels: 



Laxatives. 
Aloes. 
Magnesia. 
Podophyllum. 
Rhamnus pur- 

shiana. 
Rhubarb. 
Senna. 
Sulphur. 



Irritants, 
Colycinth. 
Croton oil. 
Elaterium. 
Jalap. 



Purges. Salines. 

Calomel. Magnesium cit- 

Castor oil. rate. 

Compound ca- Magnesium sul- 

thartic pill. phate. 

A large dose of Potassium and 
any laxative. sodium tar- 

trate. 
Seidlitz powder. 
Sodium phos- 
phate. 
Sodium sul- 
phate. 

C. To correct fermentation: Betanaphthol, thymol, sali- 
cylic acid, salol (phenyl salicylas). 

D. To remove parasites (anthelmintics) : Aspidium, beta- 
naphthol, pepo, quassia, spigelia, thymol. 

SECOND DIVISION — FOR SYSTEMIC ACTION 

Class 1. — Drugs used to act on the skin after absorption. 

A. To stimulate: Arsenic, thyroid. 

B. To decrease perspiration: Atropin. 

C. To increase perspiration (diaphoretics) : Alcohol, anti- 
pyrin, pilocarpin. 

Class 2. — Drugs used to act on the genito-urinary system. 

A. To increase the amount of urine: Buchu, caffein, digi- 
talis, scoparius, squill, water. 

B. To modify the character of the urine: Hexamethylenamin 
(urotropin), methylene blue, potassium acetate, potas- 
sium bicarbonate, potassium citrate, salicylic acid, salol. 

C. To stimulate the mucous membranes: Cantharides, copa- 
iba, cubebs, oil of santal. 

D. To increase menstruation (emmenagogues) : Iron, man- 
ganese dioxid, thyroid. 

E. To contract the uterus (oxytocics) : Ergot, hydrastis, 
quinin, viburnum. 

Class 3. — Drugs used to act on the respiratory tract. 

A. To increase the secrttion of mucous membranes (expec- 
torants) : Ammonium chlorid (small doses), ipecacu- 
anha, iodids. 

B. To decrease the secretion of the mucous membranes: 
Ammonium chlorid (large doses), atropin, codein, 
heroin, morphin, terpin hydrate. 

C. To relax spasm: Atropin, bromids, chloral, gelsemium, 
morphin, nitroglycerin, stramonium, tobacco. 



36 TREATMENT OF POISONING 

Class 4. — Drugs used to act on the circulation. 

A. To stimulate the heart: Ammonia, camphor. 

B. To depress the heart: Aconite, veratrum. 

C. To strengthen the heart: Caffein, digitalis, strophanthin, 
strychnin. 

D. To contract the blood-vessels: Atropin, ergot, supra- 
renal. 

E. To dilate the blood-vessels: Alcohol, nitrites. 

Class 5. — Drugs used to act on the nervous system. 

A. To stimulate (cerebral stimulants, antispasmodics, excito- 
motors) : Asafetida, caffein, camphor, cannabis indica, 
phosphorus, strychnin, thyroid, valerian. 

B. To depress (analgesics; depresso-motors) : Acetanilid, 
aconite, acetphenetidinum (phenacetin), antipyrin, bella- 
donna, bromids, chloral, lobelia, opium. 

C. To produce sleep (hypnotics) : Bromids, chloral, hyos- 
cin, paraldehyd, sulphonethylemethanum (trional), so- 
dium diethyl barbiturate (veronal-sodium). 

D. To produce anesthesia: General: Chloroform, ether, 
nitrous oxid. Local : cocain, ethyl chlorid, ice, menthol, 
phenol. 

Class 6. — Drugs used to lower the temperature of the body. 
Antipyretics: Acetanilid, acetphenetidinum (phenacetin), 
antipyrin, cold. 

Class 7. — Drugs used for actions which are specific. 

Antitoxins in acute infection ; cinchona in malaria ; col- 
chicum in acute gout; iodids (in small doses long con- 
tinued) in some disturbances of metabolism, notably 
sclerosis ; iron in anemia ; mercury in syphilis ; salicylic 
acid in acute arthritis ; thyroid in myxedema. 

Class 8. — Unclassified organic extracts. 

Mammary, ovarian, pancreas, parotid, pituitary, testicular, 
thymus. 

TREATMENT OF POISONING 
As the symptoms and treatment of poisoning are 
many times so similar, it seems best to divide poisons 
into classes, and then to describe the treatment of each 
class, rather than to multiply individual descriptions. 
The following classification is of types of drugs. 
The individual drugs with references to the class to 



TREATMENT OF POISONING 37 

which they belong, and therefore to the treatment 
advisable, will be found in a table on another page. 

Class 1. — Irritants of the Gastro-Intestinal Canal. 
Acids. 
Alkalies. 
Irritant metallic salts. 

Class 2. — Irritants of the Central Nervous System. 
Atropin-containing drugs. 
Cafrein-containing drugs. 
Cocain. 

Scopolamin (hyoscin). 
Strychnin. 
Volatile oils. 

Class 3. — Depressants of the Nervous and Circulatory 
Systems. 
All cardiac drugs in large doses. 
Coal-tar products. 
Cyanids. 
Hypnotics. 
Narcotic drugs. 
Nicotin. 
Most phenol-containing drugs. 

CLASS I. IRRITANTS OF THE GASTRO-INTESTINAL 

CANAL 

Most irritants in weak dilutions are astringent, while 
most astringents in strong solutions are irritant. The 
action of astringents and irritants on mucous mem- 
branes is, therefore, largely one of degree. Some 
astringents act chemically to form albuminates with 
the protein substance found on moist mucous mem- 
branes, thus coating and preventing the further irri- 
tation of the membrane. At the same time the blood- 
vessels of the membrane are contracted, the membrane 
is dried, and the secretion diminished. This is typical 
metallic astringent action. If this albuminate is insol- 
uble or very slowly soluble in the media surrounding 
it the action just described is the only action due to 
the astringent, viz., there may be more or less pro- 
nounced irritation at first, but the after-effect is seda- 
tive. If, however, this albuminate tends to dissolve 
at its junction with the mucous membrane, the action 



38 TREATMENT OF POISONING 

of astringency is then continued and may become so 
irritating as to cause severe inflammation or with some 
metallic salts or acids cause ulceration and corrosion. 
Such drugs or preparations are called "gastrointes- 
tinal irritants/' and in poisonous doses will all pro- 
duce the same immediate symptoms. Later individual 
symptoms or conditions develop due to the character 
of the substance absorbed, to its chemical nature and 
to the amount of local corrosion that it can cause. 

Different metals have different powers of astrin- 
gency and irritant action; also different salts of the 
same metal vary in the irritation which they will pro- 
duce. The acid formed after the dissociation of the 
metallic ion decides the amount of irritation that the 
salt will cause. Also the greater the ease with which 
the metallic ion is dissociated from its acid ion the 
greater the corrosion; therefore, the soluble nitrates 
and chlorids are much more corrosive than the ace- 
tates, citrates and tartrates. The sulphates are between 
these groups in their irritant effect. 

The most astringent metals in the order of their 
astringency are lead, iron, aluminum, copper, zinc and 
silver. The most astringent salt is lead acetate, while 
the most irritant salts are mercuric nitrate, mercuric 
chlorid and zinc chlorid. The sulphates and acetates 
of copper and zinc and the nitrates of silver and lead, 
if applied in weak solutions, are astringent, but are 
irritant if in large quantities or in strong solutions. 
Insoluble preparations of mercury may irritate and 
corrode, but insoluble salts of other metals are gen- 
erally only astringent. Double salts of the metals are 
less likely to irritate, because they ordinarily do not 
precipitate albumin. A styptic strongly coagulates 
albumin, and hence causes a clot which stops hemor- 
rhage. 

SYMPTOMS 

The symptoms common to all gastro-intestinal irri- 
tants are irritation or corrosion of the mouth, throat 
and esophagus, depending on the concentration of the 
poison swallowed. Other symptoms are: more or less 
gastric pain ; nausea ; vomiting, first of the contents 
of the stomach, then of mucus, then often of blood; 



TREATMENT OF POISONING 39 

later diarrhea, first of the contents of the bowels, then 
mucus, and, perhaps, blood are passed. There are 
more or less symptoms of shock due to the reflex 
action on the heart from irritation of the gastric 
branches of the pneumogastric nerve. The symptoms 
of collapse are a rapid, weak heart, dyspnea, cold sur- 
face of the body, clammy, cold perspiration,' tendency 
to syncope, and a gradual failure of the pulse. 

The symptoms of poisoning by gastro-intestinal irri- 
tants are: 

Immediate Symptoms : 
Pain. 
Nausea. 
Vomiting. 
Colic. 
Diarrhea. 
Collapse. 

Frequent After-Symptoms : 

Inflammation and ulceration of the mouth, throat and 

esophagus. 
Gastritis. 

Duodenitis (jaundice). 
Enteritis. 
Albuminuria. 
Nephritis. 
Ulceration, perforation, peritonitis. 

Possible Remote Symptoms : 

Fatty degeneration of the liver, kidneys and heart. 
Strictures from the healing of the corrosions and ulcera- 
tions. 

TREATMENT OF CORROSIVE POISONING 

Immediate Treatment : Warm water drinks contain- 
ing the antidote, if there is one (an emetic or a stom- 
ach-tube is rarely needed, and, if necessary, should be 
used with great caution and gentleness) ; albuminous 
and mucilaginous drinks, as milk, egg albumin, flax- 
seed infusions, slippery elm infusions, etc. ; hypoder- 
matic injections of morphin sufficient to stop pain 
and continued vomiting. For corrosive acids the 
most convenient antidote is usually a solution of soap. 

Treatment of Collapse : Rest, quiet ; dry heat, espe- 
cially to the region of the heart ; atropin sulphate, 



40 TREATMENT OF POISONING 

1/100 of a grain hypodermatically ; strychnin sulphate 
or nitrate, 1/30 of a grain hypodermatically; repeated 
in three hours, if needed (large doses of strychnin are 
not advisable, as it cannot stimulate the heart or raise 
the blood-pressure as so long believed) ; camphor, a 
syringeful hypodermatically of a saturated solution in 
sterile olive oil (or a ready-prepared ampoule), every 
half hour for several doses ; caffein as strong coffee, by 
rectal injection if there is no diarrhea. 

After-Treatment : Give a saline purge, if deemed 
necessary. For acute gastritis give morphin sufficient 
to stop the pain, mucilaginous drinks, rectal alimenta- 
tion. Give cardiac stimulants, if needed. Later give 
bismuth subcarbonte in large doses (2 grams or 30 
grains) twice a day; later, a milk diet. Treat duodeni- 
tis and nephritis, if they occur. Order absolute rest 
in bed for one or two weeks, if the irritation or cor- 
rosion was severe, lest perforation from ulceration be 
precipitated. Treat ulcer of the stomach and stric- 
tures, if they occur. 

CLASS II.— IRRITANTS OF THE CENTRAL NERVOUS 
SYSTEM 

The principal symptoms of poisoning by drugs of 
this class are those of irritation of the central nervous 
system. There is restlessness and nervous excitement ; 
there may be, later, delirium and convulsions, and, 
perhaps, still later, coma. The pulse is full, bounding, 
and generally rapid ; there may even be delirium cordis 
or tachycardia. Respirations are increased in rapidity, 
the face is flushed and the skin of the body feels hot 
and dry, and there often is increased temperature. 
There may be vomiting; there often is diarrhea; there 
is vesical irritability, and often strangury, depending 
on the drug. Some drugs of the atropin series may 
cause vesical paresis. There are muscular twitchings : 
there may be cramps ; and, as above stated, convul- 
sions may occur. The pupils are of course dilated if 
the poisoning is by any member of the atropin series 
or by cocain, and they often become dilated during 
cerebral excitement from other members of this group. 

The symptoms of poisoning by irritants of the cen- 
tral nervous system are: 



TREATMENT OF POISONING 41 

Immediate Symptoms : 

Gastro-intestinal burning and pain, perhaps nausea and 

vomiting, if the poison contains an aromatic or volatile 

oil. 
Cerebral excitement. 
Rapid heart. 
Rapid respiration. 
Erythemas and flushing of the face and surface of the 

body. 

Frequent After-Symptoms : 
Purging. 

Frequent urination. 
Muscular twitchings. 
Delirium. 
Convulsions. 
Coma. 
Failure of the circulation. 

Possible Remote Symptoms : 

Abortion in pregnant women. 

Albuminuria and nephritis if the poison is a renal irritant 

as are many of the volatile oils. 
Prolonged sleeplessness and nervous irritability. 

TREATMENT OF POISONING BY IRRITANTS OF THE 
CENTRAL NERVOUS SYSTEM 

Administer warm water with the antidote, if there 
is such. 

Give an emetic. The emetics in the order of their 
strength are: mustard (a tablespoonful in a glass of 
warm water) ; ipecac (2 gm. [30 grains] of powdered 
ipecac, or a tablespoonful of the syrup) ; zinc sulphate 
(2 gm. [30 grains] dissolved in water) ; copper sul- 
phate (0.50 gram [7y 2 grains] dissolved in water) ; 
apomorphin (1/10 of a grain given hypodermatically). 
Any of these emetics may be repeated in fifteen min- 
utes if there is no satisfactory result. It should be 
remembered that apomorphin is depressant to the cir- 
culation. 

Wash out the stomach by means of a stomach-tube 
if there is no satisfactory emesis. If the vomiting is 
satisfactory, continue to administer warm water until 
the stomach washes clean. 

Administer one or more nerve sedatives. The best 
are bromids and chloral, and the dose depends on the 
character of the poison. They are best administered 



42 TREATMENT OF POISONING 

by the rectum, at least provided nausea and vomiting 
is continued after the stomach has been cleared of the 
poison. If there is much circulatory depression, the 
best sedative to administer is morphin, hypodermati- 
cally, perhaps combined with scopolamin (hyoscin). 
An adjunct to the action of the morphin as a central 
nervous sedative and as a strengthener of the circula- 
tion is ergot, given intramuscularly. If there are con- 
vulsions, inhalations of chloroform are required. 

Apply dry heat to the body, if the surface is cool or 
there is a tendency to collapse. 

If heart failure occurs later in the poisoning, from 
shock or from the depression caused by nausea, such 
circulatory stimulants should be given as camphor (a 
saturated solution in olive oil hypodermatically) ; 
strophanthin (given hypodermatically or intravenously 
in a dose of 1/500 of a grain) ; epinephrin in aseptic 
ampoule or 1 c.c, 15 minims, of a 1 part to 10,000 
solution; or intramuscular injection of some aseptic 
ergot preparation (1 ampoule) and repeat in an hour, 
if needed. 

Give plenty of water with a demulcent, if there has 
been irritation of the stomach either from a volatile 
oil poisoning or from the emetic used. 

CLASS III. DEPRESSANTS OF THE NERVOUS AND 

CIRCULATORY SYSTEM 

The symptoms of poisoning by drugs of this class 
are, as their name implies, those of circulatory and 
nervous depression. The pulse is either slow or rapid, 
but generally weak ; the surface of the body generally 
becomes cold ; respirations are slowed ; pupils are gen- 
erally dilated unless the poison is morphin or nicotin ; 
often the patient becomes faint ; drowsiness soon devel- 
ops, and if a narcotic has been taken stupor soon devel- 
ops ; perhaps convulsions will occur ; later paralysis 
and coma. 

Immediate Symptoms (if the poison is a depressant of the 
nervous system) : 
Depression. 
Drowsiness. 
Slow, weak pulse. 
Slowed respiration. 
Paralysis. 
Coma. 



TREATMENT OF POISONING 43 

Later Symptoms : 

Muscular weakness. 
Circulatory weakness. 

Immediate Symptoms (if the poison is a circulatory depres- 
sant) : 

Rapid or slow, weak pulse. 

Cardiac anxiety. 

Cold, clammy perspiration. 

Face pale. 

Perhaps convulsions. 

Syncope. 

TREATMENT 

Wash out the stomach (emetics or stomach tube, as 
see above). 

Administer not only the chemical, but a physio- 
logic antidote, if there is such. 

Apply dry heat to the body. 

If the poison was a narcotic, give cerebral and 
nervous stimulation, as caffein (coffee), camphor, 
atropin, strychnin. 

If the poison was a circulatory depressant, give 
atropin, ergot, epinephrin or strophanthin, as above 
described. 

Compel prolonged mental, circulatory and physical 
rest. 

The accompanying table is arranged alphabetically. 

The second column gives the class to which the 
poison belongs, and the treatment for this class has 
been given under the headings of the general treatment 
for each class. Therefore the number of the class to 
which the poison belongs refers to the treatment there 
outlined. 

Column 3 ("special symptoms' J ) suggests symptoms 
of poisoning which are characteristic of the drug, such 
symptoms being in addition to those which are charac- 
teristic of the class of poisons to which the drug 
belongs. 

In the fourth column ("special treatment") is indi- 
cated any chemical or physiologic antidote that is valu- 
able in treating poisoning by the drug, and is an addi- 
tion to the general rules discussed above. 



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NEW AND NONOFFICIAL REMEDIES 

The following substances have been accepted by the Coun- 
cil on Pharmacy and Chemistry for inclusion in New and 
Nonofficial Remedies to Jan. 1, 1915. Not all of the prep- 
arations on the market of each drug, serum, tuberculin or 
vaccine are enumerated here. For the complete list reference 
should be had to the last edition of New and Nonofficial 
Remedies. 



AGAR AND AGAR PREPARA- 
TIONS 

Agar-Agar 

Phenolphthalein-Agar 
Agaric Acid 

ALUMINUM COMPOUNDS 

Alumnol 
ANESTHETICS 

Anesthetics, General 

Ethyl Bromide 

Ethyl Chloride 

Kelene 

Methyl Chloride 

Liquid Nitrous Oxide 
Anesthetics, Local 

Alypin 

Anesthesin 

Beta-Eucaine Hydro- 
chloride 

Beta-Eucaine Lactate 

Cycloform 

Neurocaine 

Novocaine 

Novccaine Nitrate 

Orthoform — New 

Orthoform — New Hydro- 
chloride 

Propaesin 

Stovaine 

Tropacocaine Hydrochloride 

ANTHRASOL AND SIMILAR 
TAR PRODUCTS 

Anthrasol 
ANTITHYROID PREPARA- 

TIONS 

Antithyroidin-Moebius 

Thyreoidectin 

Arbutin 

Arhovin 

ARSENIC AND ARSENIC 
COMPOUNDS 

Arsenic Compounds, Complex- 
Arsanilatcs 
Arsacetin 

Sodium Arsanilate 
Atoxyl 
Soamin 



Arsenic Compounds, Complex- 
Arsenphenol- Amines 
Neosalvarsan 
Salvarsan 
Arsenic Compounds, Complex- 
Organic-Cacodylates 
Sodium Cacodylate 
Arsenic Compounds, Complex- 
Organic 
Arsencferratin 
Arsen-Triferrin 
Elarson 
ATOPHAN AND ATOPHAN 
DERIVATIVES 
Atophan 
Isatophan 
Novatophan 
Paratophan 
A T R O P I N DERIVATIVES 
AND ANALOGUES 
Synthetic Mydriatrics 
Eumydrin 
Euphthalmin 

Homatropine Hydrochloride 
Benzene, Medicinal 
Berberine Hydrochloride 
BILE SALTS AND BILE 
SALT COMPOUNDS 
Bilein 
Bile Salts 
Colalin 
Glycotauro 
Ovogal 
BISMUTH COMPOUNDS 

Bismuth Compounds, Soluble 
Bismon 

Bismuth and Iron Citrate 
(soluble), Wellcome 
Brand 
Bismuth and Lithium Cit- 
rate (soluble) Wellcome 
Brand 
Bismuth Compounds, Insoluble 
Airol 
Bismal 

Bismuth Betanaphtholate 
Cremo-Bismuth 
Crurin Purum 
Lac Bismo 
Tannismuth 
Xeroform 



NEW AND NONOFFICIAL REMEDIES 



49 



BROMINE DERIVATIVES 

Adalin 

Brometone 

Bromipin 

Bromo-Mangan 

Bromural 

Brovalol 

Sabromin 
CALCIUM SALTS 

Calcium Glycerophosphate 

Calcium Ichthyol 

Calcium Lactate 

Calcium Peroxide 

Calcium Phenolsulphonate 

Cantharidin 

Chinosol 
CHLORAL DERIVATIVES 
AND SUBSTITUTES 

Butyl-Chloral Hydrate 

Chloralformamide 

Chloralamid 

Chlorbutanol 

Chloretone 

Methaform 

Solution Amylene-Chloral 
CODEINE DERIVATIVES 

Euccdin 

Guaiacodeine 

Compressed Oxygen 
COPPER SALTS 

Copper Citrate 
COTARNINE SALTS 

Stypticin 

Styptol 
CREOSOTE AND GUAIACOL 
COMPOUNDS 

Benzosol 

Creosote Carbonate 

Creosotal 

Creosotal-Heyden 

Guaiacodeine 

Guaiacol Carbonate 

Duotal 

Duotal-Heyden 

Guaiacol-Salol 

Guaiamar 

Gujasanol 

Monotal 

Styracol 
CRESOL AND CRESOL PREP- 
ARATIONS 

Cresol 

Disinfectant Krelos, Mul- 
ford 

Kresamine 

Phenoco 

Trikresol 
CRESOL DERIVATIVES 

Cresatin 

Europhen 

Cypress Oil 
DIETHYL-BARBITURIC ACID 
AND COMPOUNDS 

Veronal 

Sodium Diethyl-Barbiturate 

Medinal 



Veronal-Sodium 
Luminal 
Luminal-Sodium 
DIGITALIS PRINCIPLES AND 
PREPARATIONS 
Digitalis Principles 
Digitalein, Crude 
Digitalin, True 
Digitalin, "French" 
Digitalin, "German" 
Digitoxin 
Related Digitalis Principles 
Cymarin 

Ouabain, Crystallized 
Digitalis Preparations 
Digipoten 
Digipuratum 
Digitol 
Dolomol 

Emetine Hydrochloride 
Epicarin 
EPINEPHRINE - AND EPI- 
NEPHRINE PREPARATIONS 
Epinephrine 
Adrenalin 

L-Suprarenin Synthetic 
L-Suprarenin Synthetic Bi- 

tartrate 
Purified Extract of Adrenal 

Gland 

Suprarenal Liquid 

Tyramine 

ERGOT PRINCIPLES AND 

PREPARATIONS 

Cornutol 

Ergotinine Citrate 
Extract of Ergot, Purified 
Secacornin 
ETHYLENE AMINES AND 
DERIVATIVES 
Ethylene Diamine Preparations 
Ethylene Diamine 
Ethylene Diamine Solution, 

10 per cent. 
Kresamine 
Lysidin 
Piperazine Compounds 
Piperazine 
Lycetol 
Sidonal 

Fermentdiagnosticum 
FERMENTS, DIGESTIVE 
Pancreatic Ferments 
Diazyme Essence 
Diazyme Glycerole 
Holadin 
Panase 
Pankreon 
Trypsin — Armour 
Trypsin — Fairchild 
Peptic Ferments 

Elixir of Enzymes 
Essence of Pepsin — Fair- 
child 
Pegnin 



50 



NEW AND NONOFFICIAL REMEDIES 



FILICIC ACID AND RELATED 
SUBSTANCES 

Filmaron 
Fluorescein 
FORMALDEHYDE PREPARA- 
TIONS AND COMPOUNDS 
WHICH LIBERATE FOR- 
MALDEHYDE 
Formaldehyde Preparations 
Solution of Formaldehyde 
Formalin 
Trioxymethylene 
Veroform 
The Simpler Formaldehyde 
Compounds 
Formicin 
Glutol-Schleich 
FORMALDEHYDE COM- 
POUNDS ACTING MAINLY 
B Y THEIR ASSOCIATED 
CONSTITUENTS 
Empyroform 
Fortoin 
Tannoform 
HEXAMETHYLENAMINE AND 
H EXAM ETHYLEN AMINE 
COMPOUNDS 

Hexamethylenamine 
Aminpform 
Formin 
Urotropine 
Amphotropin 

Hexamethylenamine Meth- 
ylene Citrate 
Helmitol 
Hexalet 
Saliformin 
Tannopin 
FORMIC ACID COMPOUNDS 

Formic Acid 
GLYCEROPHOSPHATES 

Calcium Glycerophosphate 
Sodium Glycerophosphate 
Hediosit 
HYDROCHLORIC ACID SUB- 
STITUTES 
Acidol 
Oxyntin 
HYPOCHLORITES 

Antiformin 
HYPOPHOSPHITES 

Ammonium Hypophosphite 
Gardner's Syrup of Chem- 
ically Pure Hypophos- 
phite of Ammonium 
ICHTHYOL AND RELATED 
COMPOUNDS 
Ichthyol 

Calcium Ichthyol 
Ferrichthyol 
Ichthalbin 
Ichthargan 
Ichthoform 
Sodium Ichthyol 
Tumenol 
Tumenol- Ammonium 



IODINE COMPOUNDS 
Iodine Dusting Powders 
Airol 
Europhen 
Iodoformogen 
Thymol Iodide 
Aristol 
Vioform 
IODINE COMPOUNDS FOR 
INTERNAL USE 
Protein Compounds 
Iodalbin 
Iodo-Casein 
Iodo-Mangan 
Non-Protein Compounds 
Ferro-Sajodin 
Iodipin 
Iothion 
Sajodin 
IRON AND IRON COM- 
POUNDS 
Iron Salts, Simple 
Ferripyrine 
Ferropyrine 
Ferrous Lactate 
Iron Salts, Complex 
Arsenoferratin 
Arsentriferrin 
Bismuth and Iron Citrate 
(soluble) Wellcome 
Brand 
Ferratin 
Ferrichthyol 
Ferro-Mangan-Dieterich 
Ferro-Sajodin 
Hemaboloids 
Ovoferrin 
Proferrin 
Triferrin 
Iron Salts, ^ Complex-Hemo- 
globin D erivatives 
Hemogallol 
Hemol 
LACTIC ACID-PRODUCING 
ORGANISMS AND PREPA- 
RATIONS 

B. B. Culture 

Bacillary Milk 

Bulgara Tablets 

Culture of Bacillus Bul- 

garicus — Fairchild 
Culture of Bulgarian Bacil- 
lus — Mulford 
Kefir Fungi 
Lactampoule 
Lactic Bacillary Tablets — 

Fairchild 
Massolin 
Lanolin 
LECITHIN PREPARATIONS 
Glycerole of Lecithin 
Lecibrin 

Lecithin Solution 
Lecithol 
Neuro-Lecithin — Abbott 

LITHIUM SALTS 

Bismuth and Lithium Ci- 
trate (soluble) Wellcome 
Brand 



NEW AND NONOFFICIAL REMEDIES 



51 



MANGANESE COMPOUNDS 

Bromo-Mangan 

Ferro-Mangan 
MEDICINAL FOODS 

Liquid Mixed Foods 

Enemose 

Liquid Peptonoids 

Panopepton 

Pre-Digested Liquid Food 
— Mulford 
Dry Protein Foods 

Ciose 

Dry Peptonoids 

Erepton 

Nutrose 
Carbohydrate Foods 

Dextri-Maltose, Mead's 

Dextrose 

Levulose — Schering 
Diabetic Foods 

Casoid Diabetic Flour 

Gluten Food A, Barker's 

Gluten Food B, Barker's 

Gluten Food C, Barker's 

Hepco Flour 
Meat Extracts 
Meat Juices 
MENTHOL COMPOUNDS 

Coryfin 

Validol 
MERCURY AND MERCURY 
COMPOUNDS 
Mercuric Compounds, Organic 

Afridol 

Mercurol 
Mercuric Compounds, Inor- 
ganic 

Mercuric Benzoate 

Mercuric Cyanide 

Mercuric Oxycyanide 

Mercuric Salicylate 

Mercuric Succinimide 

Mergal 

Potassium Mercuric-Iodide 

Soloid Mercuric Potassium 
Iodide 

Sublamine 
Mercurous Compounds 

Calomelol 
Mercury, Metallic 

Electr-HG 

Mercurial Ointment, Im- 
proved — Mulford 
MORPHIN DERIVATIVES 

Diacetyl-Morphin 

Heroin 

Diacetyl-Morphine Hydro- 
chloride 

Heroin Hydrochloride 

Ethyl-Morphine Hydro- 

chloride 

Dionin 

Morphine Meconate 
NAPHTHOL COMPOUNDS 

Alumnol 



Betanaphthol Benzoate 
Betol 

Bismuth Betanaphtholate 
Ninhydrin 
NITRATES-ORGANIC 

Erythrol Tetranitrate 
NUCLEINS AND NUCLEIC 
ACIDS 

Nuclein 
Nucleic Acid 
Sodium Nucleate 
Nuclein — Abbott 
ORGANS OF ANIMALS 
Leukocytes 

Leukocyte Extract 
Leucocyte Extract — Squibb 
Mammary Gland 

Mammary Substance — 
Armour 
Ovary 

Ovarian Substance — 

Armour 
Desiccated Corpus Luteum 

— Armour 
Lutein Tablets— H. W. & 
Co. 
Thyroid 

Iodothyrine 
Parathyroid Gland 

Desiccated Parathyroid 

Gland — Armour 
Pituitary Gland 

Desiccated Pituitary Sub- 
stance (Anterior Lobe) — 
Armour 
Desiccated Pituitary Sub- 
stance (Posterior Lobe) 
— Armour 
Pituitary Body Desiccated 

— Armour 
Pituitary Liquid 
Solution Pituitary Extract 
Red Bone-Marrow 

Extract of Red Bone-Mar- 
row 
Thymus Gland 

Desiccated Thymus — 

Armour 
Osmium Tetroxide 
Oxaphor 
PARSLEY-SEED PREPARA- 

TIONS 
Apiol 
Oleoresin of Parsley-Seed 

PERBORATE PREPARATIONS 

Sodium Perborate 
Perogen Bath 
PEROXIDES 

Hydrogen Peroxide Prepara- 
tions 
Perhydrol 

Metallic Peroxides 
Calcium Peroxide 
Magnesium Peroxide 
Magnesium Perhydrol 



52 



NEW AND NONOFFICIAL REMEDIES 



PEROXIDES — Metallic — Con- 
tinued. 

Magnesium Perhydrol 

Sodium Peroxide 

Oxone 

Strontium Peroxide 

Zinc Peroxide 

Peroxide Zinc Soap 
Organic Peroxides 

Acetozone 

Alphozone 
PHENETIDIN DERIVATIVES 

Acetphenetidin 

Phenacetin 

Chinaphenin 

Eupyrine 

Holocaine Hydrochloride 

Lactophenin 

Phenocoll Hydrochloride 

Phenocoll Salicylate 

Salophen^ 

Thermodin 

Triphenin 
PHENOCOLL COMPOUNDS 

Phenocoll Hydrochloride 

Phenocoll Salicylate 

Phenolphthalein 
PHENOLSULPHONATES 

Calcium Phenolsulphonate 

Phenolsulphonephthalein 

Phenolsulphonephthalein — 
H. W. & Co. 

Phloridzin 

Picric Acid 

Placentapepton 
Pollantin, Fall 

Pollantin Powder, Fall 
PYRAZOLON DERIVATIVES 
Antipyrine Compounds and 
Derivatives 

Antipyrine Salicylate 

Salipyrin 

Melubrin 

Ferripyrme 

Ferropyrine 
Pyramidon and Pyramidon 
Compounds 

Pyramidon 

Pyramidon Acid Camphor- 
ate 

Pyramidon Neutral Cam- 
phorate 

Pyramidon Salicylate 
PYROGALLOL DERIVATIVES 

Eugallol 

Pyroxylin 

Celloidin 
QUININE DERIVATIVES 

Aristochin 

Chinaphenin 

Euquinine 

Quinine Lygosinate 

Quinine Tannate 

Quinine and Urea Hydro- 
chloride 

Saloquinine 

Saloquinine Salicylate 



RADIUM AND RADIUM 
SALTS 

Radium Bromide 
Radium Carbonate 
Radium Chloride 
Radium Sulphate 
RESORCIN COMPOUNDS 

Euresol 
SALICYLIC ACID COM- 
POUNDS 
Acid Derivatives of Salicylic 
Acid (Acetylsalicylic Acid 
Type) 
Aspirin 
Diaspirin 
Diplosal m 
Novaspirin 
Alkyl Derivatives of Salicylic 
Acid (Methyl-S alkylate 

Type) 
Benzosalin 
Ethyl Salicylate 
Sal-Ethyl 
Mesotan 
Spirosal 
Phenol Derivatives of Salicylic 
Acid (Salol Type) 
Betol 

Guaiacol-Salol 
Salophen 
Salicylic Compounds in Which 
the Salicylate Action is Sub- 
ordinate 
Antipyrine Salicylate and 

Salipyrin 
Mercuric Salicylate 
Phenocoll Salicylate 
Saliformin 
Saloquinine 
Saloquinine Salicylate 
Santyl 
SANDALWOOD OIL DERIVA- 
TIVES 

Arrheol 
Carbosant 
Santyl 
Thyresol 

Scarlet R Medicinal, Bie- 
brich 
SCOPOLAMINE 

Euscopol 
SERUMS AND VACCINES 

I. Antibodies Used for Pro- 
phylactic or Therapeutic 
Purposes 
Normal Horse-Serum 
Diphtheria Antitoxin Un- 

concentrated 
Diphtheria Antitoxin Con- 
centrated 
Diphtheria Antitoxin, Dried 
Tetanus Antitoxin, Uncon- 

centrated 
Tetanus Antitoxin, Concen- 
trated 
Tetanus Antitoxin, Dried 
Anti-Anthrax Serum 



NEW AND NONOFFICIAL REMEDIES 



53 



SERUMS AND VACCINES— 

Antibodies — Continued. 

Antidysenteric Serum 
Antigonococcus Serum 
Antimeningococcus Serum 
Antipneumococcus Serum 
Antistaphylococcus Serum 
Antistreptococcus Serum 

II. Antigens Used for Prophy- 
lactic or Therapeutic Pur- 
poses 

Vaccine Virus — Virus Vac- 

cinium 
Antirabic Vaccine 
Old Tuberculin 
New Tuberculin, T. R. 
New Tuberculin, B. E. 
Tuberculin Denys, B. F. 
Detre Differential Test 
Tuberculosis Serum Vac- 
cine, S. B. E. 
Dixon's Tubercle Bacilli 

Extract 
Dixon's Suspension of 

Dead Tubercle Bacilli 
Tuberculin — Rosenbach 
Acne Bacillus Vaccine 
Cholera Vaccine 
Colon Bacillus Vaccine 
Diphtheria Bacillus Vaccine 
Friedlaender Bacillus Vac- 
cine 
Gonococcus Vaccine 
Meningococcus Vaccine 
Micrococcus Neoformans 

Vaccine 
Pertussis Bacillus Vaccine 
Plague Bacillus Vaccine 
Pneumococcus Vaccine 
Pyocyaneus Bacillus Vac- 
cine 
Staphylococcus Vaccines 
Streptococcus Vaccine 
Typhoid Vaccine 
Erysipelas and Prodigiosus 
Toxins 

III. Diagnostic Agents 

Bass Modification of the 
Widal Test 

Borden's Modification of 
the Widal Test 

Noguchi Modification of 
the Wassermann Test 

Luetin 

Silk Peptone "Hoechst" 
SILVER COMPOUNDS 
Silver Salts, Simple 

Albargin 

Argentamin 

Silver Citrate 

Antiseptic-Crede 

Silver Lactate 

Silver Lactate-Crede 
Silver Salts, Complex 

Argonin 

Argyrol 

Hegonon 

Ichthargan 

Novargan 

Protargol 

Scphol 



Silver Preparations, Colloidal 

Cargentos 

Collargol 

Electrargol 

Sodium Acid Phosphate 

Sodium Lygosinate 

Sodium Oleate 

Sodium Succinate, Exsic- 
cated 
SULPHANILATES 

Sulphanilic Acid 

Soloid Nizin 
SULPHONE METHANES 

Sulphonmethane 

Sulphonal 

Sulphonethylmethane 

Trional 

Sulphurated Potash 
SULPHUR COMPOUNDS 

Calcium Ichthyol 

Ferrichthyol 

Ichthaibin 

Ichthargan 

Ichthoform 

Ichthyol 

Sodium Ichthyol 

Thigenol 

Thiol 

Tumenol 

Tumenol Ammonium 
TANNIC AND GALLIC ACID 
DERIVATIVES 
Tannic Acid Derivatives 

Protan 

Tannalbin 

Tannigen 

Tannismuth 

Tannoform 

Tannopin 
Gallic Acid Derivatives 

Airol 

Bismal 

Gallogen 

Lenigallol 
TERPINE DERIVATIVES 

Apinol 

Oil of Pine Needles 

THIOSINAMINE AND THIO- 

SINAMINE COMPOUNDS 

Thiosinamine 

Fibrolysin 
UREASE 

Arlco-Urease 

Urease-Dunning 
URETHANES (CARBAMATES), 
UREA AND UREIDS 

Adalin 

Ethyl Carbamate 

Urethane 

Urethan — Hoechst 

Euphorin 

Hedonal 

Thermodin 

Urea 

Veronal 



fff 



54 



NEW AND NONOFFICIAL REMEDIES 



VALERIC ESTERS 

Amyl Valerate 
Bromural 
Brovalol 
Validol 

Validol Camphoratum 
Valyl 
Borne ol Valerates 
Bornyval 
New-Bornyval 
Gynoval 
XANTHINE DERIVATIVES 
Theobromine and Theobromine 
Compounds 
Theobromine 
Agurin 

Theobromine Sodium Sali- 
cylate 



Thephorin 

Uropherin — B. 

Uropherin — S. 
Theophyllin and Theophyllin 
Compounds 

Theophyllin 

Theophyllin — Boehringer 

Theocin 

Theophyllin Sodio-Acetate 

Acet-Theocin Sodium 

Acet-Theophyllin Sodium 
YEAST PREPARATIONS 

Cerolin 

Xerase 
ZINC COMPOUNDS 

Zinc Permanganate 

Zinc Peroxide 



USEFUL DRUGS 
A book has been prepared by the Council on Pharmacy 
and Chemistry, entitled "Useful Drugs." It discusses a 
selected list of remedies, including only those drugs which 
usage has proved are efficient and reliable. A list of these 
drugs follows : 

Acacia. — Acacia, U. S. P. 

Mucilago Acaciae. — Mucilage of Acacia, U. S. P. 
Acetanilidum. — Acetanilid, U. S. P. Dosage : 0.20 gm. or 3 grains. 
Acetphenetidinum. — Acetphenetidin, XL S. P. Dosage : 0.50 gm. or iy 2 

grains. 
Acidum Aceticum. — Acetic Acid, U. S. P. 

Diluted Acetic Acid, U. S. P. 
Acidum Acetylsalicylicum. — See under Aspirin. 

Acidum Benzoicum. — Benzoic Acid, U. S. P. Dosage: 0.5 gm. or iy 2 
grains. 
Glyceritum Boroglycerini. — Glycerite of Boroglycerin, U. S. P. 
Unguentum Acidi Borici. — Ointment of Boric Acid, U. S. P. 
Acidum Citricum. — Citric Acid, U. S. P. Dosage : 0.5 gm. or iy 2 grains. 
Acidum Diaethylbarbituricum. — See under Veronal. 
Acidum Hydrochloricum. — Hydrochloric Acid, U. S. P. 

Acidum Hydrochloricum Dilutum. — Diluted Hydrochloric Acid, U. S. P. 
Dosage : 1 c.c. or 15 minims. 
Acidum Hydrocyanicum Dilutum. — Diluted Hydrocyanic Acid, IT. S. P. 

Dosage : 0.1 c.c. or 1.5 minims. 
Acid Nitricum. — Nitric Acid, U. S. P. 
Acidum Picricum. — Picric Acid, N. N. R. (to be added). Dosage: 0.025 

to 0.1 gm. or y 2 to 2 grains; used locally in 1 per cent, solution. 
Acidum Salicylicum. — Salicylic Acid, U. S. P. Dosage: 0.5 gm. or 7^ 

grains. 
Acidum Tannicum. — Tannic Acid, U. S. P. Dosage : 0.3 gm. or 5 grains. 
Glyceritum Acidi Tannici. — Glycerite of Tannic Acid, TJ. S. P. Dosage: 

1 c.c. or 15 minims. 

Tannalbin. — Tannalbin, N. N. R. Dosage: 2 gm. or 30 grains. 
Aconitum. — Aconite, U. S. P. 

Tinctura Aconiti. — Tincture of Aconite, U. S. P. Dosage: 0.2 c.c. or 3 
minims. 
Adeps. — Lard, U. S. P. 

Adeps Benzoinatus. — Benzoinated Lard, U. S. P. 

Adeps Lanae Hydrosus. — Hydrous Wool Fat, U. S. P. 
Adrenalin. — See Epinephrine. 
Aether. — Ether, U. S. P. Dosage : 1 c.c. or 15 minims. 

Spiritus Aetheris, U. S. P. Dosage : 4 c.c. or 1 fluidram. 

Spiritus Aetheris Compositus. U. S. P. (to he deleted). Dosage: 4 c.c. 
or 1 fluidram. 

Aether Nitrosus. — Used only in the form of 

Spiritus Aetheris Nitrosi. — Spirit of Nitrous Ether, U. S. P. Dosage: 

2 c.c. or 30 minims. 

Aethylis Chloridum.— Ethyl Chloride, U. S. P. 

Aethyl-Morphinae Hydrochloridum.— Ethyl-Morphin Hydrochloride, N. N. 

R. Dionin. Dosage : 0.015 gm. or *4 grain. 
Alcohol.— Alcohol, U. S. P. 

Elixir Aromaticum. — Aromatic Elixir, U. S. P. 



56 USEFUL DRUGS 

Aloes— Aloe, U. S. P. Dosage : 0.15 to 0.3 gm. or 2 to 5 grains, purgative ; 
0.03 to 0.05 gm. or % to 1 grain, laxative. 
Extractum Aloes. — Extract of Aloes, U. S. P. Dosage : 0.10 gm. or 2 

grains. 
Aloinum. — Aloin, U. S. P. Dosage : 0.05 gm. or 1 grain. 
Alu men.— Alum, U. S. P. 

Alumen Exsiccatum. — Exsiccated Alum, U. S. P. 
Alumini Acetas. — Aluminum Acetate. 

Liquor Alumini Acetatis. — Solution of Aluminum Acetate, N. F. 
Ammonia. 

Aqua Ammoniae. — Ammonia Water, U. S. P. 
Linimentum Ammoniae. — Ammonia Liniment, U. S. P. 
Ammonii Acetas. — Ammonium Acetate. 

Liquor Ammonii Acetatis. — Solution of Ammonium Acetate, TJ. S. P. 
Dosage : 15 c.c. or 4 fluidrams. 
Ammonii Carbonas. — Ammonium Carbonate, IT. S. P. Dosage: 0.25 gm. 
or 4 grains. 
Spiritus Ammoniae Aromaticus. — Aromatic Spirit of Ammonia, U. S. P. 
Dosage : 1 to 5 c.c. or 15 to 60 minims. 
Ammonii Chloridum. — Ammonium Chloride, U. S. P. Dosage: 0.30 to 1 

gm. or 5 to 15 grains. 
Amylis Nitris. — Amyl Nitrite, U. S. P. Dosage : 0.2 c.c. or 3 minims, by 

inhalation. 
Amylum. — Starch, Corn Starch, TJ. S. P. 

Antimonii et Potassii Tartras. — Antimony and Potassium Tartrate. 
U. S. P. Dosage : 0.001 gm. or 1/60 grain. 
Vinum Antimonii. — Wine of Antimony, U. S. P. Dosage: 1 c.c. or 15 
minims (0.004 gm. or 1/15 grain tartar emetic). 
Apomorphinae Hydrochloridum. — Apomorphine Hydrochloride, U. S. P. 
Dosage: expectorant 0.002 gm. or 1/30 grain, emetic 0.005 gm. or 
1/10 grain. 
Antipyrina. — Antipyrine, U. S. P. Dosage : 0.25 gm. or 4 grains. 
Aqua.— Water, U. S. P. 

Aqua Destillata. — Distilled Water, U. S. P. 
Argenti Nitras. — Silver Nitrate, U. S. P. Dosage: 0.01 gm. or 1/5 grain. 

Argenti Nitras Fusus. — Molded Silver Nitrate, U. S. P. 
Argenti Proteinas. — Silver Proteinate. See Protargol, N. N. R. 
Aristol. — See Thymolis Iodidum. 

Arseni Trioxidum. — Arsenic Trioxide, U. S. P. Dosage : 0.002 gm. or 
1/30 grain. 
Liquor Acidi Arsenosi. — Solution of Arsenous Acid, U. S. P. Dosage : 

0.2 c.c. or 3 minims. 
Liquor Arseni et Hydrargyri lodidi. — Solution of Arsenous and Mercuric 

Iodids, TJ. S. P. Dosage: 0.1 c.c. or 1V 2 minims. 
Liquor Potassii Arsenitis. — Solution of potassium Arsenite, TJ. S. P. 
Dosage : 0.2 c.c. or 3 minims. 
Asafoetida. — Asafetida, TJ. S. P. Dosage : 0.25 gm. or 4 grains. 
Aspidium. — Aspidium, TJ. S. P. 

Oleoresina Aspidii. — Oleoresin of Aspidium, T T . S. P. Dosage: 2 gm. 
or 30 grains. 
Aspirin. — Aspirin, N. N. R. Dosage : 0.3 to 1 gm. or 5 to 15 grains. 
Atophan. — Atophan, N. N. R. (to be added). Dosage: 0.5 to 1 gm. or 

7V 2 to 15 grains. 
Atoxyl. — See Sodii Arsanilas. 

Atropina. — Atropine, TJ. S. P. Dosage : 0.00025 gm. or 1/250 gr. 
Atropinae Sulphas. — Atropine Sulphate, TJ. S. P. Dosage: 0.4 mg. or 

1/160 grain. 
Bacterial Vaccines. — See Vaccines. 
Balsamum Peruvianum.- Balsam of Peru, TJ. S. P. 
Balsamum Tolutanum.— Balsam of Tolu, U. S. P. 

Syrupus Tolutanus. Syrup of Tolu. TJ. S. P. Dosage: 16 c.c. or 4 
fluidrams. 



USEFUL DRUGS 57 

Belladonnae Folia. — Belladonna Leaves, U. S. P. 
Tinctura Belladonnae Foliorum. — Tincture of Belladonna Leaves, U. S. 

P. Dosage: 0.5 c.c. or 8 minims. 
Extractum Belladonnae Foliorum. — Extract of Belladonna Leaves, U. S. 

P. Dosage : 0.01 gm. or 1/5 grain. 
Emplastrum Belladonnae. — Belladonna Plaster, U. S. P. 
Unguentum Belladonnae. — Belladonna Ointment, U. S. P. 
Benzoin urn. — Benzoin, U. S. P. 
Tinctura Benzoinae Composita. — Compound Tincture of Benzoin, 
TJ. S. P. 
Benzosulphinidum. — Benzosuiphinide, Saccharin, U. S. P. Dosage: 0.2 

gm. or 3 grains. 
Betanaphthol. — Betanaphthol, U. S. P. Dosage : 0.1 to 0.3 gm. or 2 to 

5 grains. 
Bismuthi Subcarbonas. — Bismuth Subcarbonate, U. S. P. Dosage: 1 gm. 

or 15 grains. 
Bismuthi Subgallas. — Bismuth Subgailate, U. S. P. Dosage: 0.25 gm. or 

4 grains. 
Eismuthi Subnitras. — Bismuth Subnitrate, U. S. P. Dosage: 1 gm. or 15 

grains. 
Bismuthi Subsalicylas. — Bismuth Subsalicylate, U. S. P. Dosage: 0.25 

gm. or 4 grains. 
Caffeina. — Caffeine, U. S. P. Dosage : 0.06 gm. to 0.3 gm. or 1 to 5 grains. 
Caffeina Citrata. — Citrated Caffeine, U. S. P. Dosage : 0.1 gm. or 2 
grains. 
Cafreinae Sodio-Benzoas. — Caffeine Sodio-Benzoate, N. F. Dosage: 0.10 

gm. or 2 grains. 
Calcii Carbonas Praecipitatus. — Precipitated Calcium Carbonate, U. S. P. 

Dosage : 1 to 3 gm. or 15 to 45 grains. 
Calcii Chloridum. — Calcium Chloride, U. S. P. Dosage : 0.5 gm. or 1% 

grains. 
Calcii Hypophosphis. — Calcium Hypophosphite, U. S. P. (to be deleted). 

Dosage : 0.5 gm. or 7^ grains. 
Calcii Lactas. — Calcium Lactate, N. N. R. Dosage: 0.5 gm. or ~y 2 grains. 
Calcii Phosphas Praecipitatus. — Precipitated Calcium Phosphate, U. S. P. 

(to be deleted). Dosage: 1 gm. or 15 grains. 
Calx.— Calcium Oxide, U. S. P. 

Liquor Calcis. — Solution of Calcium Hydroxide, U. S. P. Dosage : 15 

c.c. or 4 fluidrams. 
Linimentum Calcis. — Lime Liniment, L T . S. P. 
Calx Chlorinata.— Chlorinated Lime, Chlorinated Calcium Oxide, U. S. P. 
Liquor Sodae Chlorinatae.— Solution of Chlorinated Soda, U. S. P. 
Dosage : 1 c.c. or 15 minims. 
Camphora. — Camphor, TJ. S. P. Dosage: 0.10 gm. or about 2 grains. 
Aqua Camphorae. — Camphor Water, U. S. P. Dosage: 10 c.c. or 2 

fluidrams. 
Spiritus Camphorae. — Spirit of Camphor, TJ. S. P. Dosage : 1 c.c. or 

15 minims. 
Linimentum Camphorae. — Camphor Liniment, TJ. S. P. 
Cannabis Indica. — Indian Cannabis, U. S. P. (to be deleted). 

Extractum Cannabis Indicae. — Extract of Indian Cannabis, U. S. P. (to 

be deleted). Dosage: 0.01 gm. or 1/5 grain. 
Tinctura Cannabis Indicae. — Tincture of Indian Cannabis, V. S. P. 
(to be deleted). Dosage: 0.5 c.c. or about 8 minims. 
Cantharis. — Cantharides, U. S. P. 

Ceratum Cantharidis. — Cantharides Cerate, TJ. S. P. 
Capsicum. — Capsicum, U. S. P. Dosage: 0.05 gm. or about 1 grain. 
Tinctura Capsici. — Tincture of Capsicum, TJ. S. P. Dosage : 0.5 c.c. 
or 7V 2 minims. 
Carbo Ligni. — Charcoal, TJ. S. P. Dosage : 1 gm. or 15 grains. 



58 USEFUL DRUGS 

Cardamom urn. — Cardamom, U. S. P. 
Tinctura Cardamomi. — Tincture of Cardamom. Dosage : 5 c.c. or 1 
fluidram. 
Caryophyllus. — Cloves, U. S. P. 

Oleum Caryophylli. — Oil of Cloves, U. S. P. Dosage : 0.2 c.c. or 3 
minims. 
Cera Alba. — White Wax, U. S. P., is the bleached form of 

Cera Flava.— Yellow Wax, U. S. P. 
Chenopodii Oleum.— Oil of Chenopodium, U. S. P. (to be added). Dosage: 

0.2 c.c. or 3 minims. 
Chloralum Hydratum.— Hydrated Chloral, U. S. P. Dosage: 0.30 to 1.30 

gm. or 5 to 20 grains. 
Chloroform.— Chloroform, U. S. P. Dosage: 0.05 to 0.3 c.c. or 1 to 5 
minims. 
Aqua Chloroformi. — Chloroform Water, U. S. P. Dosage : 15 c.c. or 

4 fluidrams. 
Spiritus Chloroformi. — Spirit of Chloroform, U. S. P. Dosage: 2 c.c. 

or 30 minims. 
Linimentum Chloroformi. — Chloroform Liniment, U. S. P. 
Chromii Trioxidum. — Chromium Trioxide, U. S. P. 
Chrysarobinum. — Chrysarobin, U. S. P. 

Unguentum Chrysarobini. — Chrysarobin Ointment, U. S. P. 
Cinchona. — Cinchona, U. S. P. 
Tinctura Cinchonae. — Tincture of Cinchona, U. S. P. Dosage : 4 c.c. 

or 1 fluidram. 
Tinctura Cinchonae Composita. — Compound Tincture of Cinchona, U. S. 
P. Dosage : 4 c.c. or 1 fluidram. 
Cinnamomum. — Cinnamon, U. S. P. 

Oleum Cinnamomi. — Oil of Cinnamon, U. S. P. Dosage: 0.05 c.c. or 

1 minim. 
Aqua Cinnamomi.— Cinnamon Water, U. S. P. Dosage: 15 c.c. or 4 
fluidrams. 
Cocaina. — Cocaine, U. S. P. Dosage : 0.03 gm. or y 2 grain. 
Cocainae Hydrochloridum. — Cocaine Hydrochloride, U. S. P. Dosage : 

0.03 gm. or y 2 grain. 
Codeina. — Codeine, U. S. P. Dosage : 0.03 gm. or y 2 grain. 
Codeinae Phosphas.— Codeine Phosphate, U. S. P. Dosage: 0.03 gm. or 

V 2 grain. 
Codeinae Sulphas.— Codeine Sulphate, U. S. P. Dosage: 0.03 gm. or y 2 

grain. 
Colchici Semen.— Colchicum Seed, U. S. P. 

Tinctura Colchici Seminis. — Tincture of Colchicum Seed, U. S. P. 
Dosage : 2 c.c. or 30 minims. 
Collodium.— Collodion, U. S. P. 

Collodium Flexile.— Flexible Collodion, U. S. P. 
Colocynthis.— Colocynth, U. S. P. 

Extractum Colocynth idis. — Extract of Colocynth, U. S. P. • Dosage : 

0.03 gm. or y 2 grain. 
Extractum Colocynthidis Compositum. — Compound Extract of Colocynth. 
U. S. P. Dosage: 0.5 gm. or iy 2 grains. 
Copaiba — Copaiba, U. S. P. Dosage : 1 c.c. or 15 minims. 
Creosotum. — Creosote, U. S. P. Dosage : 0.2 c.c. or 3 minims. 
Cresol. — Cresol, U. S. P. Dosage : 0.05 c.c. or 1 minim. 

Liquor Cresolis Compositus. — Compound Solution of Cresol, U. S. P. 
Dosage : solutions containing 1 to 5 per cent. 
Cupri Sulphas.— Copper Sulphate, U. S. P. Dosage: 0.01 gm. or 1/5 

grain, astringent; 0.3 gm. or 5 grains (not repeated), emetic. 
Diacetyl-Morphinae Hydrochloridum.— Heroin Hydrochloride, N. N. R. 
Dosage: 3 mg. or 1/20 grain. 



USEFUL DRUGS 59 

Digitalis. — Digitalis, XL S. P. Dosage : 0.065 gm. or 1 grain. 
Infusum Digitalis. — Infusion of Digitalis, U. S. P. Dosage: 8 c.c. or 

2 fluidrams. 
Tinctura Digitalis. — Tincture of Digitalis, U. S. P. Dosage : 1 c.c. or 
15 minims. 
Diphtheria Antitoxin. — See Serum Antidiphthericum. 
Elaterinum. — Elaterin, U. S. P. Dosage: 0.005 gm. or 1/10 grain. 
Emetinae Hydrochloridum. — Emetine Hydrochloride, N. N. R. (to be 
added). Dosage: 0.03 to 0.45 gm. or from % to % grain as an 
amebicide. 
Epinephrine. — Epinephrine, N. N. R. Dosage : 1 :10,000 to 1 :1,000. 

Internally, 5 to 10 drops of 1 :1,000 solution. 
Ergota. — Ergot, U. S. P. Dosage : 2 gm. or 30 grains. 

Fluidextractum Ergotae.— Fluidextraet of Ergot, U. S. P. Dosage : 
2 c.c. or 30 minims. 
Eucalyptus. — Eucalyptus, U. S. P. 
Eucalyptol. — Eucalyptol, U. S. P. Dosage : 0.3 c.c. or 5 minims. 
Oleum Eucalypti. — Oil of Eucalyptus, U. S. P. Dosage: 0.5 c.c. or 8 
minims. 
Fel Bovis.— Oxgall, U. S. P. 
Fel Bovis Purificatum. — Purified Oxgall, U. S. P. Dosage: 0.5 gm. or 
7% grains. 
Ferri Carbonas. — Ferrous Carbonate. 

Massa Ferri Carbon atis. — Mass of Ferrous Carbonate, U. S. P. Dosage : 

0.25 gm. or 4 grains. 
Pilulae Ferri Carbon atis. — Pills of Ferrous Carbonate, U. S. P. 
Dosage : 2 pills. 
Ferri Chloridum. — Ferric Chloride, U. S. P. 
Tinctura Ferri Chloridi. — Tincture of Ferric Chloride, U. S. P. Dosage: 
0.5 c.c. or 8 minims. 
Ferri et Ammonii Citras. — Iron and Ammonium Citrate, U. S. P. Dosage: 

0.25 gm. or 4 grains. 
Ferri lodidum. — Ferrous Iodide. 
Syrupus Ferri lodidi. — Syrup of Ferrous Iodide, U. S. P. Dosage : 
1 c.c. or 15 minims. 
Ferri Phosphas Solubilis. — Soluble Ferric Phosphate, U. S. P. Dosage : 

0.25 gm. or 4 grains. 
Ferri Sulphas. — Ferrous Sulphate, U. S. P. Dosage : 0.2 gm. or 3 grains. 

Ferri Sulphas Exsiccatus. — Exsiccated Ferrous Sulphate, U. S. P. 
Ferrum. — Iron, U. S. P. 
Ferrum Reductum. — Reduced Iron, U. S. P. Dosage: 0.06 gm. or 1 
grain. 
Formaldehydum. — Formaldehyde. 

Liquor Formaldehydi. — Solution of Formaldehyde, U. S. P. 
Gelatinum.— Gelatin, U. S. P. 
Gentiana. — Gentian, U. S. P. 
Tinctura Gentianae Composita. — Compound Tincture of Gentian, U. S. P. 

Dosage : 4 c.c. or 1 fluidram. 
Extractum Gentianae.— Extract of Gentian, U. S. P. Dosage : 0.25 gm. 
or 4 grains. 
Glandulae Thyroideae Siccae. — Desiccated Thyroid Glands, U. S. P. 

Dosage : 0.05 gm. or 1 grain. 
Glycerinum. — Glycerin, U. S. P. 

Suppositoria Glycerini. — Suppositories of Glycerin, U. S. P. 
Glycerylis Nitras. — Glyceryl Trinitrate. 

Spiritus Glycerylis Nitratis.— Spirit of Glyceryl Trinitrate, U. S. P. 
Dosage : 0.05 c.c. or 1 minim. 



_ 



60 USEFUL DRUGS 

Glycyrrhiza. — Glycyrrhiza, Licorice Root, U. S. P. 

Fluidextractum Glycyrrhizae. — Fluidextract of Glycyrrhiza, U. S. P. 

Dosage : 2 c.c. or 30 minims. 
Pulvis Glycyrrhizae Compositus. — Compound Powder of Glycyrrhiza, 
U. S. P. Dosage : 4 gm. or 60 grains. 
Guaiacol. — Guaiacol, U. S. P. Dosage: 0.1 to 0.6 c.c. or iy 2 minims 

to 10 minims. 
Guaiacolis Carbonas. — Guaiacol Carbonate, U. S. P. Dosage: 1 gm. or 

15 grains. 
Heroin Hydrochloride. — See Diacetylmorphinae Hydrochloridum. 
Hexamethylenamina. — Hexamethylenamine, U. S. P. Dosage: 0.3 gm. 

or 5 grains. 
Homatropinae Hydrobromidum. — Homatropine Hydrobromide, U. S. P. 

Dosage: 0.0005 gm. or 1/125 grain. 
Hydrargyri Chloridum Corrosivum. — Corrosive Mercuric Chloride, U. S. P. 

Dosage : 0.002 to 0.01 gm. or 1/30 to 1/6 grain. 
Hydrargyri Chloridum Mite. — Mild Mercurous Chloride, U. S. P. Dosage: 

0.005 to 0.02 gm. or 1/10 to 1/3 grain. 
Hydrargyri lodidum Flavum. — Yellow Mercurous Iodide, U. S. P. Dosage : 

0.015 gm. or % grain. 
Hydrargyri lodidum Rubrum. — Red Mercuric Iodide, U. S. P. Dosage: 

0.003 or 1/20 grain. 
Hydrargyri Oxidum Flavum. — Yellow Mercuric Oxide, U. S. P. Dosage : 
0.5 to 2 per cent, ointment. 
Unguentum Hydrargyri Oxidi Flavi. — Ointment of Yellow Mercuric 
Oxide, U. S. P. Dosage : It should be diluted with from 10 to 100 
parts of petrolatum. 
Hydrargyri Salicylas. — Mercuric Salicylate, N. N. R. Dosage : 0.6 c.c. or 

10 minims of a 10 per cent, suspension in liquid paraffin. 
Hydrargyrum. — Mercury, U. S. P. 

Hydrargyrum cum Creta. — Mercury with Chalk, U. S. P. Dosage : 0.250 

gm. or 4 grains. 
Massa Hydrargyri. — Mass of Mercury, U. S. P. Dosage : 0.250 gm. or 

4 grains. 
Unguentum Hydrargyri. — Mercurial Ointment, U. S. P. 
Unguentum Hydrargyri Dilutum. — Blue Ointment, U. S. P. Dosage : 2 
gm. or 30 grains. 
Hydrargyrum Ammoniatum. — Ammoniated Mercury, U. S. P. 
Unguentum Hydrargyri Ammoniati. — Ointment of Ammoniated Mercury, 
U. S. P. 
Hydrastis. — Hydrastis, U. S. P. 

Fluidextractum Hydrastis.— Fluidextract of Hydrastis, U. S. P. Dosage : 
2 c.c. or 30 minims. 
Hydrogenii Dioxidum. — Hydrogen Dioxide. 
Aqua Hydrogenii Dioxidi. — Solution of Hydrogen Dioxide, U. S. P. 
Dosage : Apply diluted with four volumes of water. 
Hyoscyamus. — Hyoscyamus, U. S. P. 
Tinctura Hyoscyami. — Tincture of Hyoscyamus, U. S. P. Dosage: 0.6 
to 2 c.c. or 10 to 30 minims. 
Ichthyol.— Ichthyol, N. N. R. Dosage : 0.2 to 2 c.c. or 3 to 30 minims. 
lodoformum. — Iodoform, U. S. P. Dosage: 0.25 gm. or 4 grains. 
lodum. — Iodine, U. S. P. 
Tinctura lodi. — Tincture of Iodine, U. S. P. Dosage: 0.1 c.c. or 1*6 
minims. 
Ipecacuanha. — Ipecac, U. S. P. Dosage: 0.05 gm. or 1 grain, expectorant; 
1 gm. or 15 grains, emetic. 
Fluidextractum Ipecacuanhae. — Fluidextract of Ipecac, U. S. P. Dosage: 

1 c.c. or 15 minims, emetic; 0.05 c.c. or 1 minim, expectorant. 
Syrupus Ipecacuanhae. — Syrup of Ipecac, TJ. S. P. Dosage: 0.25 c.c. 
or 4 minims, expectorant ; 15 c.c. or 4 fluidrams, emetic. 



USEFUL DRUGS 61 

Jalapa. — Jalap, U. S. P. Dosage : 1 gm. or 15 grains. 

Pulvis Jalapae Compositus.— Compound Powder of Jalap, U. S. P. 
Dosage : 2 gm. or 30 grains. 
Linum. — Flaxseed, L\ S. P. 

Oleum Lini. — Linseed Oil, U. S. P. Dosage : 30 c.c. or 1 fluidounce. 
Lobelia.— Lobelia, U. S. P. 
Tinctura Lobeliae. — Tincture of Lobelia, U. S. P. Dosage : 0.5 c.c. to 
1.5 c.c. or 10 to 20 minims. 
Magnesii Carbonas. — Magnesium Carbonate, U. S. P. Dosage : 3 gm. or 

45 grains. 
Magnesii Citras. — Magnesium Citrate. 

Liquor Magnesii Citratis. — Solution of Magnesium Citrate, U. S. P. 
Dosage : 360 c.c. or 12 fluidounces. 
Magnesii Oxidum. — Magnesium Oxide, U. S. P. Dosage : 0.6 to 3 gm. 

or 10 to 45 grains. 
Magnesii Sulphas. — Magnesium Sulphate, U. S. P. Dosage: 15 gm. or 
240 grains. 
Magnesii Sulphas EfFervescens. — Effervescent Magnesium Sulphate, U. 
S. P. Dosage : 15 gm. or 240 grains. 
Mentha Piperita. — Peppermint, U. S. P. 
Oleum Menthae Piperitae. — Oil of Peppermint, U. S. P. Dosage : 0.2 

c.c. or 3 minims. 
Spiritus Menthae Piperitae. — Spirit of Peppermint, U. S. P. Dosage: 2 

c.c. or 30 minims. 
Aqua Menthae Piperitae. — Peppermint Water, U. S. P. Dosage : 16 
c.c. or 4 fluidrams. 
Menthol. — Menthol, U. S. P. Dosage : 0.065 gm. or 1 grain. 
Methylis Salicylas. — Methyl Salicylate, U. S. P. Dosage : 1 c.c. or 15 
minims. 
Oleum Betulae.— Oil of Betula, U. S. P. 
Oleum Gaultheriae. — Oil of Gaultheria, U. S. P. 
Morphina. — Morphine, U. S. P. Dosage : 0.01 gm. or 1/6 grain. 

Morphinae Hydrochloridum. — Morphine Hydrochloride, U. S. P. Dosage: 

0.01 gm. or 1/6 grain. 
Morphinae Sulphas. — Morphine Sulphate, IL S. P. Dosage: 0.01 gm. 
or 1/6 grain. 
Morrhuae Oleum. — Cod-Liver Oil, U. S. P. Dosage : 1 dram to 1 ounce. 
Myrrh a. — Myrrh, U. S. P. Dosage : 0.5 gm. or 7% grains. 
Tinctura Myrrhae. — Tincture of Myrrh, U. S. P. Dosage : 1 c.c. or 
15 minims. 
Nux Vomica. — Xux Vomica, U. S. P. 

Extractum Nucis Vomicae. — Extract of Xux Vomica, V. S. P. Dosage: 

0.015 gm. or ^ grain. 
Tinctura Nucis Vomicae. — Tincture of Xux Vomica, U. S. P. Dosage: 
0.6 c.c. or 10 minims. 
Opium — Opium, V. S. P. 

Opii Pulvis. — Powdered Opium, U. S. P. Dosage, 0.065 gm. or 1 grain. 
Extractum Opii. — Extract of Opium, U. S. P. Dosage: 0.03 gm. or V2 

grain. 
Tinctura Opii. — Tincture of Opium, Laudanum, U. S. P. Dosage : 0.5 

c.c. or 8 minims. 
Tinctura Opii Deodorati. — Tinctura of Deodorized Opium, U. S. P. 

Dosage : 0.5 c.c. or 8 minims. 
Tinctura Opii Camphorata. — Camphorated Tincture of Opium, Paregoric, 

U. S. P. Dosage : 8 c.c. or 2 fluidrams. 
Pulvis Ipecacuanhae et Opii.— Powder of Ipecac and Opium, U. S. P. 
Dosage: 0.5 gm. or 7V 2 grains. 
Oxygenium Compressum. — Compressed Oxygen, X. X. R. 
Pancreatinum. — Pancreatin, U. S. P. Dosage: 0.5 gm. or 7y 2 grains. 



62 USEFUL DRUGS 

Paraffin urn. — Paraffin, U. S. P. 

Paraldehydum. — Paraldehyde, U. S. P. Dosage : 2 c.c. or 30 minims. 

Pelletierinae Tannas. — Pelletierine Tannate, U. S. P. Dosage: 0.25 gm. 

or 4 grains. 
Pepsinum. — Pepsin, U. S. P. Dosage: 0.25 gm. or 4 grains. 
Petrolatum. — Petrolatum, U. S. P. 

Petrolatum Liquidum. — Liquid Petrolatum, U. S. P. 
Phenol. — Phenol, U. S. P. 

Phenol Liquefactum. — Liquefied Phenol, U. S. P. Dosage : 0.05 c.c. or 

1 minim. 
Phenolphthalein.— Phenolphthalein, N. N. R. Dosage : 0.05 to 0.5 gm. 

or 1 to 8 grains. 
Phenylis Salicylas.— Phenyl Salicylate, U. S. P. Dosage : 0.2 to 0.5 gm. 

or 3 to 8 grains. 
Phosphorus. — Phosphorus, U. S. P. Dosage : 0.5 mg. or 1/125 grain. 
Physostigma. — Physostigma, U. S. P. 

Physostigminae Salicylas. — Physostigmine Salicylate, U. S. P. Dosage: 

1 mg. or 1/60 grain. 
Physostigminae Sulphas. — Physostigmine Sulphate, U. S. P. Dosage : 

1 mg. or 1/60 grain. 
Pilocarpus. — Pilocarpus, U. S. P. 

Pilocarpinae Hydrochloridum. — Pilocarpine Hydrochloride, U. S. P. 

Dosage: 0.001 to 0.01 gm. or 1/60 to 1/6 grain. 
Pilocarpinae Nitras. — Pilocarpine Nitrate, TJ. S. P. Dosage : 0.01 

gm. or 1/5 grain. 
Pituitary Extract. — Pituitary Extract, N. N. R. (to be added). Dosage: 

1 c.c. or 15 minims. 
Pix Liquida.— Tar, TJ. S. P. 

Unquentum Picis Liquidae. — Tar Ointment, TJ. S. P. 
Plumbi Acetas. — Lead Acetate, TJ. S. P. Dosage: 0.065 gm. or 1 grain. 

Liquor Plumbi Subacetatis. — Solution of Lead Subacetate, TJ. S. P. 
Podophyllum. — Podophyllum, TJ. S. P. 

Resina Podophylli. — Resin of Podophyllum, U. S. P. Dosage: 0.003 

to 0.006 gm. or 1/20 to 1/10 grain. 
Potassii Acetas. — Potassium Acetate, TJ. S. P. Dosage : 2 gm. or 30 

grains. 
Potassii Bicarbonas. — Potassium Bicarbonate, TJ. S. P. Dosage : 2 gm. 

or 30 grains. 
Potassii Bitartras. — Potassium Bitartrate, TJ. S. P. Dosage : 2 gm. or 30 

grains. 
Potassii Bromidum. — Potassium Bromide, TJ. S. P. Dosage: 1 gm. or 15 

grains. 
Potassii Carbonas. — Potassium Carbonate, TJ. S. P. Dosage : 1 gm. or 15 

grains, well diluted. 
Potassii Chloras. — Potassium Chlorate, TJ. S. P. Dosage : Saturated solu- 
tion may be used as mouth wash or gargle. 
Potassii Citras. — Potassium Citrate, TJ. S. P. Dosage : 1 gm. or 15 grains. 
Potassii Citras Effervescens. — Effervescent Potassium Citrate, U. S. P. 

Dosage : 4 gm. or 60 grains. 
Potassii et Sodii Tartras. — Potassium and Sodium Tartrate, TJ. S. P. 

Dosage : 8 gm. or 120 grains. 
Pulvis Effervescens Compositus. — Seidlitz Powder, U. S. V. Dosage : 

One set of two papers. 
Potassii Hydroxidum. — Potassium Hydroxide, TJ. S. P. 

Liquor Potassii Hydroxidi. Solution of Potassium Hydroxide, U. S. P. 

Dosage: 1 c.c. or 15 minims. 
Potassii lodidum.— Potassium l.xlido. V. S. P. Dosage: 0.3 to 2 gm. 

or 5 to 30 grains. 
Potassii Permanganas.- Potassium Permanganate, U. S. P. Dosage: 0.03 

to 0.06 gm. or y 2 to 1 grain. 



USEFUL DRUGS 63 

Protargol — Protargol, N. N. R., Silver Proteinate. Dosage: 1.2,000 to 

1 per cent, solutions. 
Prunus Virginiana. — Wild Cherry, U. S. P. 
Syrupus Pruni Virginianae. — Syrup of Wild Cherry, U. S. P. Dosage: 
5 c.c. or 1 fluidram. 
Quinina. — Quinine, U. S. P. Dosage: 0.25 gm. or 4 grains. 
Quininae Bisulphas. — Quinine Bisulphate, U. S. P. Dosage : 0.25 gm. or 

4 grains. 
Quininae Hydrochloridum. — Quinine Hydrochloride, U. S. P. Dosage: 

0.25 or 4 grains. 
Quininae Sulphas. — Quinine Sulphate, U. S. P. Dosage: 0.25 gm. or 4 

grains. 
Quininae Tannas. — Quinine Tannate, N. N. R. Dosage: 0.5 gm. or IVz 

grains. 
Quininae et Ureae Hydrochloridum. — Quinine and Urea Hydrochloride, 

N. N. R. Dosage : 0.25 gm. or 4 grains. 
Resina. — Resin, U. S. P. (to be deleted). 

Resorcinol. — Resorcinol, U. S. P. Dosage : 0.125 gm. or 2 grains. 
Rhamnus Purshiana. — Cascara Sagrada, U. S. P. 
Fluidextractum Rhamni Purshianae. — Fluidextract of Cascara Sagrada, 

U. S. P. Dosage : 1 c.c. or 15 minims. 
Fluidextractum Rhamni Purshianae Aromaticum. — Aromatic Fluidex- 
tract of Cascara Sagrada, U. S. P. Dosage : 0.6 to 2 c.c. or 10 to 30 
minims. 
Extractum Rhamni Purshianae. — Extract of Cascara Sagrada, U. S. P. 
Dosage : 0.1 to 0.5 gm. to 2 to 8 grains. 
Rheum. — Rhubarb, U. S. P. Dosage : 1 gm. or 15 grains. 

Extractum Rhei.— Extract of Rhubarb. U. S. P. Dosage : 0.25 gm. or 

4 grains. 
Tinctura Rhei Aromatica. — Aromatic Tincture of Rhubard, U. S. P. 

Dosage : 2 c.c. or 30 minims. 
Syrupus Rhei Aromaticus. — Aromatic Syrup of Rhubarb, U. S. P. 
Dosage : 8 c.c. or 2 fluidrams. 
Ricini Oleum. — Castor Oil, U. S. P. Dosage: 15 c.c. or 4 fluidrams. 
Rosa. — Rose 
Oleum Rosae.— Oil of Rose, U. S. P. 
Aqua Rosae. — Rose Water, U. S. P. 
Saccharum. — Sugar, U. S. P. 
Syrupus. — Syrup, U. S. P. 
Saccharum Lactis. — Sugar of Milk, U. S. P. 
Salvarsan. — Salvarsan, N. N. R. Dosage: 0.5 gm. or iy 2 grains. 

Neosalvarsan. — Dosage: 0.75 gm. or 12 grains. 
Santali Oleum. — Oil of Santal, U. S. P. Dosage : 0.5 c.c. or 8 minims. 
Santoninum. — Santonin, U. S. P. Dosage : 0.065 gm. or 1 grain. 
Sapo.— Soap, U. S. P. 

Linimentum Saponis. — Soap Liniment, U. S. P. 
Sapo Mollis.— Soft Soap, U. S. P. 
Sarsaparilla. — Sarsaparilla, U. S. P. 
Syrupus Sarsaparillae Compositus.— Compound Syrup of Sarsaparilla, 
U. S. P. Dosage : 16 c.c. or 4 fluidrams. 
Scilla. — Squill, U. S. P. Dosage : 0.125 gm. or 2 grains. 

Tinctura Scillae. — Tincture of Squill, U. S. P. Dosage : 1 c.c. or 15 

minims. 
Syrupus Scillae.— Syrup of Squill, U. S. P. Dosage : 2 c.c. or 30 
minims. 
Scopolaminae Hydrobromidum. — Scopolamine Hydrobromide, U. S. P. 
Dosage: 0.5 mg. or 1/125 grain. 



64 USEFUL DRUGS 

Senna. — Senna, U. S. P. Dosage: 4 gm. or 60 grains. 

Fluidextractum Sennae. — Fluidextract of Senna, U. S. P. Dosage: 2 

c.c. or 30 minims. 
Syrupus Sennae. — Syrup of Senna, U. S. P. Dosage : 4 c.c. or 1 

fluidram. 
Serum Antidiphthericum. — Antidiphtheric Serum, Diphtheria Antitoxin, 

U. S. P. Dosage : Immunizing, 500 to 1,000 units ; curative, 10,000 

units. 
Serum Antitetanicum. — Antitetanic Serum, N. N. R. Dosage : Immuniz- 
ing, 1,500 units; in tetanus, 3,000 to 20,000 units. 
Sin apis. — Mustard. 

Sinapis Nigra. — Black Mustard, U. S. P. Dosage: 8 gm. or 120 grains. 

Charta Sinapis. — Mustard Paper, U. S. P. 

Oleum Sinapis Volatile. — Volatile Oil of Mustard, U. S. P. Dosage : 

0,008 c.c. or y 2 minim. 
Sodii Arsanilas. — Sodium Arsanilate, N. N. R. Dosage: 0.02 gm. or 1/3 

grain. 
Sodii Arsenas. — Sodium Arsenate, U. S. P. Dosage : 5 mg. or 1/10 grain. 
Sodii Benzoas. — Sodium Benzoate, IT. S. P. Dosage : 1 gm. or 15 grains. 
Sodii Bicarbonas. — Sodium Bicarbonate, U. S. P. Dosage : 1 gm. or 15 

grains. 
Sodii Biphosphas. — Sodium Acid Phosphate, N. N. R. (to he added). 

Dosage : 1 to 1.5 gm. or 15 to 20 grains. 
Sodii Boras. — Sodium Borate, U. S. P. Dosage: 0.5 gm. or iy 2 grains. 
Sodii Bromidum. — Sodium Bromide, U. S. P. Dosage: 1 gm. or 15 grains. 
Sodii Cacodylas. — Sodium Cacodylate, N. N. R. Dosage : 0.03 gm. or % 

grain. 
Sodii Carbonas Monohydratus. — Monohydrated Sodium Carbonate, U. S. P. 

Dosage : 0.25 gm. or 4 grains. 
Sodii Chloridum. — Sodium Chloride, TJ. S. P. Dosage: 16 gm. or 240 

grains, emetic ; 4 gm. or 60 grains, laxative. 
Sodii Hydroxidum. — Sodium Hydroxide, U. S. P. 

Liquor Sodii Hydroxidi. — Solution of Sodium Hydroxide, U. S. P. 

Dosage : 1 c.c. or 15 minims. 
Sodii lodidum. — Sodium Iodide, U. S. P. Dosage: 0.5 gm. or 7V 2 grains. 
Sodii Nitris. — Sodium Nitrite, U. S. P. Dosage : 0.065 or 1 grain. 
Sodii Phosphas. — Sodium Phosphate, U. S. P. Dosage : 2 gm. or 30 

grains. 
Sodii Phosphas Effervescens. — Effervescent Sodium Phosphate, U. S. P. 

Dosage : 8 gm. or 120 grains. 
Sodii Salicylas. — Sodium Salicylate, U. S. P. Dosage : 1 gm. or 15 grains. 
Sodii Sulphas. — Sodium Sulphate, U. S. P. Dosage : 16 gm. or 240 grains. 
Sodii Sulphis. — Sodium Sulphite, IT. S. Y. Dosage : Applications of 1 

in 10 or 1 dram to the ounce. 
"'Sodii Thiosulphas. — Sodium Thiosulphate, U. S. P. Dosage: 1 gm. or 15 

grains. 
Sparteinae Sulphas. — Sparteine Sulphate, II. S. P. (to be deleted). 

Dosage : 0.01 gm. or 1/5 grain. 
Staphylococcus Vaccine. — See Vaccine, Staphylococcus. 
Stramonium. — Stramonium, IT. S. P. 
Strophanthinum.— Strophanthin, U. S. P. Dosage: 0.0003 gm. or 1 '200 

grain. 
Strophantus. — Strophantus, U. S. P. 
Tinctura Strophanti. — Tinctura of Strophantus, V. S. P. Dosage: 

0.5 c.c. or 8 minims. 
Strychnfna.— Strychnine, r. s. P. Dosage: 0.0005 to o.oor. or 1/100 

to 1/10 grain. 
Strychninae Nitras. —Strychnine Nitrate, U. S. P. Dosage: 0.001 gm. 

or 1/60 grain. 
Strychninae Sulphas. Strychnine Sulphate, V. S. P. Dosage: 0.001 

gm. or 1/60 grain. 



USEFUL DRUGS 65 

Su I phonal. — See under Sulphonniethanum. 

Sulphonethylmethanum. — Sulphonethylmethane, U. S. P. — Trional. 

Dosage : 1 gm. or 15 grains. 
Sulphonmethanum. — Sulphonmethane, U. S. P. — Sulphonal. Dosage: 1 

gm. or 15 grains. 
S u I p h u r. — Sulphur. 

Sulphur Lotum. — Washed Sulphur, U. S. P. Dosage : 4 gm. or 60 

grains. 
Sulphur Praecipitatum. — Precipitated Sulphur, U. S. P. Dosage : 4 gm. 

or 60 grains. 
Sulphur Sublimatum. — Sublimed Sulphur, U. S. P. Dosage: 4 gm. 

or 60 grains. 
Unguentum Sulphuris. — Sulphur Ointment, U. S. P. 
L-Suprarenin Synthetic. — See Epinephrine. 
Tannalbin. — See under Acidum Tannicum. 
Terebinthina. — Turpentine, U. S. P. 

Oleum Terebinthinae. — Oil of Turpentine, U. S. P. Dosage : 1 c.c. or 

15 minims. 
Terpini Hydras. — Terpin Hydrate, U. S. P. Dosage: 0.125 gm. or 2 

grains. 
Tetanus Antitoxin. — See under Serum Antitetanicum. 
Theobromatis Oleum. — Oil of Theobroma, TJ. S. P. 
Theobromina. — Theobromine, N. X. R. Dosage : 0.3 gm. or 5 grains. 
Theobrominae Sodio-Salicylas. — Theobromine Sodium Salicylate, N. N. 

R. — Diuretin. Dosage : 0.5 gm. or 7% grains. 
Thymol. — Thymol, U. S. P. Dosage : 0.1 gm. or 2 grains. 
Thymolis lodidum. — Thymol Iodide, U. S. P. 
Typhoid Vaccine. — See Vaccine, Typhoid. 

Tiglii Oleum. — Croton Oil, TJ. S. P. Dosage: 0.05 c.c. or 1 minim. 
Tragacantha. — Tragacanth, U. S. P. 
Trional. — See under Sulphonethylmethanum. 
Tuberculinum. — Tuberculin, X. N. R. 
Urotropin. — See Hexamethylenamina. 
Vaccine, Staphylococcus. — Staphylococcus Vaccine, N. N. R. (to be 

added). Dosage: 1,000,000,000 bacteria. 
Vaccine, Typhoid. — Typhoid Vaccine, N. N. R. (to be added). Dosage: 

500,000,000 to 1,000,000,000 bacteria. 
Vaccine Virus. — See under Virus, Vaccine. 
Valeriana. — Valerian, U. S. P. 

Tinctura Valerianae Ammoniata. — Ammoniated Tincture of Valerian, 

TJ. S. P. Dosage : 2 c.c. or 30 minims. 
Veronal. — N. N. R. Dosage: 0.3 to 0.6 gm. or 5 to 10 grains. 
Sodii Diaethyl-Barbituras.— Sodium Diethyl-Barbiturate, N. N. R. 

Dosage : 0.3 to 0.6 gm. or 5 to 10 grains. 
Viburnum Prunifolium. — Viburnum Prunifolium, V. S. P. (to be deleted). 
Fluidextractum Viburni Prunifolii. — Fluidextract of Viburnum Pruni- 
folium, TJ. S. P. (to be deleted). Dosage: 2 c.c. or 30 minims. 
Virus Vaccinum. — Vaccine Virus, X. X'. R. 

Zinci Acetas. — Zinc Acetate, tJ. S. P. Dosage : 0.125 gm. or 2 grains. 
Zinci Chloridum. — Zinc Chloride, U. S. P. 

Liquor Zinci Chloridi. — Solution of Zinc Chloride, TJ. S. P. 
Zinci Oxidum. — Zinc Oxide, TJ. S. P. Dosage : 0.25 gm. or 4 grains. 

Unguentum Zinci Oxidi. — Ointment of Zinc Oxide. 
Zinci Stearas. — Zinc Stearate, U. S. P. 

Zinci Sulphas. — Zinc Sulphate, TJ. S. P. Dosage : 2 gm. or 30 grains. 
Zingiber. — Ginger, U. S. P. Dosage : 1 gm. or 15 grains. 
Tinctura Zingiberis. — Tincture of Ginger, U. S. P. Dosage : 2 c.c. or 

30 minims. 



GENERAL INFECTIOUS DISEASES 



INDIVIDUAL TENDENCIES 

Teachers of therapeutics emphasize the necessity of 
individualizing the patient, but even they sometimes 
forget the importance of family tendencies. There is 
no more doubt that an individual inherits family weak- 
ness and family strength, or, if the phrase is preferred, 
family tendencies, than there is that he inherits the 
features and general physique of his parents and 
grandparents. 

While it may be going a step backward to speak of 
temperaments, we certainly should consider, as pointed 
out by Duckworth, the tendencies of the individual. 
These tendencies are often recognizable by the general 
appearance and physical findings but if not can almost 
always be developed by a careful investigation into the 
family history of the patient. 

THE FAMILY HISTORY 

It should be the rule of the physician to inquire into 
the family history as carefully with every new patient 
as is required in an insurance examination. 

Heredity and environment are the two factors that 
are most prominent in the production of physical and 
mental health. Environment may improve or mar 
heredity, but cannot change it. Heredity is therefore 
the most important factor in raising and developing 
an ideal race. The importance of good environment 
for the perpetuation of physical and mental health is 
so well understood that it requires no discussion. But 
environment will not eliminate a hereditary tendency to 
disease or to mental or physical insufficiency. Neither 
will environment develop perfect mental and physical 
health when there is an inherited deficiency, although 
environment can markedly improve deficiency caused 
by injury or acquired by disease. 

The environment of prospective fathers and 
mothers and their future children is being constantly 
improved by the public health advances now being 



UNSCIENTIFIC PRESCRIBING 67 

made in all communities, but as has been stated, this 
will not prevent the ravages of inherited disease 
(syphilis, epilepsy, insanity, imbecility, physical weak- 
ness) or of the inherited tendency to disease (tuber- 
culosis, cancer, gout, diabetes, alcoholism, etc.), any 
more than environment can produce twins, beauty, 
geniuses or permanent health. In fact, improved 
environment is doing more for the defectives in all 
lines than for those of good heredity, who would 
survive a less improved environment. 

It, therefore, is of vital importance to the patient 
that his physician should know and recognize the dia- 
thesis or predisposition to certain types of disease that 
he has inherited, so that whatever treatment his pres- 
ent condition may call for, the tendency to the family 
weakness may be at the same time properly combated. 

UNSCIENTIFIC PRESCRIBING 

Lack of scientific therapeutic teaching causes a large 
number of general practitioners to listen to enthusias- 
tic proprietary detail men and subsequently to use a 
preparation for a given condition the active ingredient 
of which the teacher of medicine may have long used, 
but in a simpler and less expensive manner. The 
physician using such a preparation and obtaining good 
results frequently rushes into print and lauds the 
preparation or combination of drugs as a cure for that 
condition or disease, when really it is the principal 
active ingredient of it that did the work, and which 
perhaps had been used for that purpose for years. 

The thing needed, then, in scientific therapeutics is 
more careful instruction in details by the teachers and 
bedside clinicians, and, as pointed out by Gottheil, a 
willingness on the part of the general practitioner to 
describe his failures as well as his successes. Also the 
general practitioner who writes of his therapeutic suc- 
cesses should constantly bear in mind, first, the trend 
of troublesome conditions to recovery; second, that it 
is not always the last drug, preparation or treatment 
that benefited the patient, but that the previous treat- 
ment really caused the cure; third, that many a new 
drug or new preparation offered with the enthusiasm 



68 PAIN 

of the physician cures a patient by psychic effect, much 
as often does a change of physicians or a change of 
environment. 

THERAPEUTICS MORE THAN MEDICINE 

A disease can not be correctly treated unless the fol- 
lowing facts are considered : 

1. Can the etiologic factor in a given disease be dis- 
covered, and can it be removed? This is the primary 
treatment. 

2. What physiologic processes in this patient are 
disturbed by this disease? The aim of all treatment 
should be the attempt to correct such disturbed physi- 
ology, and at the same time not to disturb the normal 
physiologic processes. 

3. The pathologic conditions which are the result of 
the disease should be removed, if possible; ameliora- 
ted if removal is not possible ; and never irritated or 
made worse by any medicinal or physical treatment. 
Special care should be taken that whatever treatment 
is deemed advisable for the patient, it should not aggra- 
vate or make worse the pathologic condition present. 

4. The symptoms and signs of the disease which in 
their totality determine the diagnosis, and the extent to 
which the pathology of the disease has progressed, are 
in their totality of minor and secondary importance in 
the treatment. On the other hand, individual trouble- 
some symptoms must be removed or ameliorated, else 
normal physiologic processes which are necessary to 
recovery can not be performed, and toxemias that 
otherwise need not have occurred may perhaps be the 
determining cause of the non-recovery of the patient. 

PAIN AS A SYMPTOM 

Of all symptoms, that of pain Is the most important 
and the one from which the patient must have relief. 
It does not seem to make a great deal of difference 
whether such pain is pathologically excusable or pres- 
ent only on account of psychologic mistake, the ner- 
vous irritability and finally depression caused by it must 
be taken into consideration and must be treated or, 
better, managed. At least, pain must be prevented at 
any cost. This does not mean that the physician should 



MEASLES 69 

hasten to the use of unneeded narcotics, nor that he 
should ever use a narcotic without regret and without 
the extra supervision that should always go with such 
treatment, but it is the skillful, thoughtful, discrim- 
inating physician who can determine the best method 
of eradicating the symptom of pain in each individual 
patient. We should remember that is frequently 
possible, in making examinations or in treating 
patients, to secure for him great comfort merely by 
altering the posture. Pain after operation is fre- 
quently due to lack of support of the back. Inci- 
dentally the soothing effects of the warm bath or the 
warm pack should not be overlooked. The use of olive 
oil in gastro-intestinal pain is worthy of consideration. 
It is commonly possible by the use of such means to 
relieve pain without the employment of any narcotic. 

MEASLES 

THE PROPHYLAXIS OF MEASLES 

Measles is a disease to which practically every indi- 
vidual who has not already suffered an attack is sus- 
ceptible. It is one of the most contagious of all dis- 
eases, ranking in this respect with smallpox and 
typhus fever. 

It seems almost invariably true that one attack of 
the disease protects against subsequent attacks, though 
most writers teach that a second, third, and even 
fourth attack are not uncommon. It is probable that 
when these repeated attacks are alleged to have occur- 
red, some of them at least were other cutaneous infec- 
tious diseases, especially so-called German measles, or 
some eruptive but non-contagious disease. 

It has been observed that children under six months 
of age are less likely to take this disease than older 
children, and that extremely old people are also less 
susceptible. Also, it seems to be a fact that the disease 
is most disastrous in its effects on infants, on children 
who have scrofulous glands, on persons who are tuber- 
culous, or who have any tendency to tuberculosis, on 
individuals who are debilitated from any cause, and on 
women who are pregnant or who have recently been 
confined. 



70 PROPHYLAXIS OF MEASLES 

The above being true, effort should be made to iso- 
late children who are suffering from measles in order 
to prevent the spread of the disease, at least to people 
in whom an attack of the disease is likely to be fol- 
lowed by disastrous results. 

The contagious element of measles appears to have 
less vitality and to resist the ordinary measures of 
disinfection, including sunlight and fresh air, much less 
strongly than does the contagium of scarlet fever. It 
seems to exist extensively in the secretions from the 
nose, throat and mouth, and the disease seems to be 
especially contagious during the period when the 
catarrhal symptoms are manifest, but before the cuta- 
neous eruption appears. This increases the difficulty 
of enforcing efficient quarantine. When the disease 
is prevalent, children who show symptoms of cold in 
the head should be suspected of perhaps having meas- 
les and should be promptly quarantined, but at the 
beginning of an epidemic it is rare that a child will be 
placed in quarantine before the eruption has appeared. 

When the rule is extended so as to apply to these 
patients, both whooping-cough and measles will be less 
rapidly passed around among the children. 

The measures enumerated as applicable to scarlet 
fever and which are also applicable to cases of measles 
may be briefly summarized as follows : 

The isolation of the patient in a remote room of the 
house. 

The selection of a single immune person to care for 
the patient. 

The wearing by the physician of a linen or rubber 
coat, when he visits the patient, which is removed out- 
side of the patient's door. 

The destruction of books and toys,' which have been 
used by the patient, at the end of the period of 
quarantine. 

The disinfection of dishes and clothing before they 
are removed from the sickroom. 

At the end of the period of quarantine, which in the 
case of measles unattended by complications should be 
three weeks, the bathing and shampooing of the 
patient, and dressing him in fresh clothes. 



TREATMENT OF MEASLES 71 

The disinfection of the room, after it has been 
vacated, by exposure of the room so far as possible to 
fresh air and sunshine. 

Sunshine and light are essential to the killing of the 
germs of all disease, and especially of measles; hence 
the room of a patient suffering from measles should 
only rarely be kept dark daring the day. The patient's 
eyes may be efficiently protected from light by blue or 
smoked glasses. 

The prolonged cough of measles after the period of 
quarantine is over should be treated as though the 
patient had incipient tuberculosis, and then the number 
of secondary deaths from measles will be cut in half. 

TREATMENT 

A patient with measles must be isolated. The room 
must be warm, as these patients should not be sub- 
jected to cold drafts or cold air. Chilling is espe- 
cally harmful in measles. This does not mean that 
the air of the room should not be fresh and clean, and 
the ventilation the best possible. 

Eyes. — Unless the child is very young and cannot 
wear colored spectacles, the room should not be dark. 
Sunlight is as essential for the welfare of patients 
with measles as it is in any other disease. It is 
absolutely unnecessary, in ordinary cases, to have the 
room black dark on account of the eyes. If the eyes 
are inflamed, the child will cooperate and really enjoy 
using colored spectacles. Of course, when it is time 
for the child to go to sleep, the room may be dark- 
ened, and the glasses removed. 

A saturated boric acid solution may be used as a 
wash for the eyes, and if it seems advisable, some sim- 
ple eye-drops may be used, such as : 

Gm. or c.c. 

B Acidi borici I 25 gr. v 

Aquae camphorae 15 A3 ivss 

Aquae q.s. ad 25 1 A3 i 

M. Sig. : Use as eye-drops three or four times a day. 

If the lids tend to stick together after sleeping, 
they should be gently washed with warm boric acid 
solution or plain warm water, and before the child 



L 



12 COUGH IN MEASLES 

goes to sleep the edges of the lids may be anointed 
with thick white petrolatum. 

Cough, Etc. — If old enough, the child should gargle 
several times a day with some simple, warm, alkaline 
sedative solution. If the child is not old enough to 
gargle, the throat should be sprayed. The nose should 
also be sprayed occasionally, if it seems stopped up. 
However, it is often well to leave the nose alone in 
measles. Most nasal douching is inadvisable, as 
tending to force fluid or secretions into the eustachian 
tubes. 

Most of these patients require some simple expec- 
torant mixture, although many physicians are losing 
faith in the activity of so-called expectorant drugs. 
There is no safe drug that promotes the secretion of 
the mucous membrane of the upper air passages and 
bronchial tubes more than does ammonium chlorid. 
It is of advantage in causing the cough to be less dry, 
and therefore aiding the expulsion of any mucopuru- 
lent matter that may be in the trachea and bronchial 
tubes. Also, if the cough is excessive from irrita- 
tion, a sedative should be added to prevent the unnec- 
essary coughing. A child 5 years old may receive the 
following : 

Gm. or ex. 

fy Codeinae sulphatis 1 05 gr. i 

Ammonii chloridi 3\ 3i 

Syrupi tolutani 50 1 A3 ii 

Aquae q.s. ad 100 1 AS iv 

M. Sig. ; A teaspoonful, in water, every two or three hours, 
when the child is awake. 

If the child's cough is not excessive or irritating, 
the codein may be omitted from the mixture. As 
soon as the expectoration is more free and there is no 
excessive amount of coughing, the medicine may be 
stopped. A child 10 years old should receive twice 
the amount of codein sulphate, and the ammonium 
chlorid should be increased to 5 gm., and if deemed 
advisable, the sour sirup of citric acid may be sub- 
stituted for the sweet sirup of tolu in amount of 
25 c.c. to the 100 c.c. mixture. 

Bozvels. — In the beginning of the disease, the child 
should receive a small dose of calomel, 0.05 or 0.10 
gm. (1 to \y 2 grains) given with milk; or a dose 



CONVALESCENCE IN MEASLES 73 

of castor oil, or some rhubarb or cascara; at least, 
the bowels should be thoroughly and well moved. 
Minute doses of calomel frequently repeated should 
not be given, as such dosage causes irritation and no 
benefit. Subsequently the bowels should be moved 
daily with some gentle laxative, if such is needed. 

Diet. — The food depends on the temperature, and 
should be liquid and simple as long as the tempera- 
ture is elevated. As soon as the temperature falls 
to normal, the child should receive good nutritious 
food, and plenty of it. It is inadvisable to give meat 
in any form, including broths, as long as the eruption 
is present. If, as has been suggested, the eruption 
in measles is caused by some irritant circulating in 
the blood, such as occurs in urticaria, representing a 
sort of anaphylaxis, the proper diet comprises cereals, 
milk, and plenty of water. Such little patients are 
better without fruits, as sometimes even orangeade 
or lemonade seems to cause more itching and discom- 
fort of the skin. 

Fever. — The temperature rarely calls for much 
treatment. If it is high, however, one or two doses 
of acetanilid will generally be sufficient to reduce it. 
Hot sponging will cool the child as much as cold 
sponging will, and with less disturbance. Cold spong- 
ing in measles is inadvisable. As often as the child 
is bathed or sponged for temperature, the surface of 
the body should be powdered with some bland talcum. 

Skin. — Unless the room is cold and damp, or the 
patient is otherwise ill, a cotton nightdress will cause 
less itching and discomfort than would a warmer flan- 
nel or silk shirt. All through the illness the nurse 
should recognize that it is the secretions of the nose 
and throat that cause infection of others, and not 
the eruption or exfoliation from the skin. This does 
not mean that it is not necessary to sterilize the 
child's garments and bedclothing, as such may carry 
the infection from the nose and throat. 

Convalescence. — Prolonged, careful convalescence 
is essential in measles. Measles, like whooping cough, 
is often a forerunner of pulmonary tuberculosis. 
Probably no attack of measles ever occurs that does 
not cause enlargement and more or less inflammation 



74 SCARLET FEVER 

of the bronchial glands. If such glands harbor 
tubercle bacilli, they are stimulated to cause an acute 
infection. On the other hand, immediately after an 
attack of measles a patient is doubtless more sus- 
ceptible to infection from tubercle bacilli. Therefore, 
before the child is returned to school the cough should 
have ceased, his weight should be normal, and his 
nutrition should be good. 

Persistent enlarged glands in the neck or elsewhere, 
and adenoid conditions or enlarged tonsils, should all 
be regarded with suspicion. Such conditions are 
liable to be accentuated by an attack of measles, and 
proper treatment should be instituted. A suppurating 
ear must be treated by a specialist until pronounced 
cured and the hearing is as near perfect as possible. 
The physician should remember that most defective 
ears follow measles, scarlet fever and influenza; that 
an acutely infected ear, if immediately correctly 
treated, is generally saved intact; distention and per- 
foration may occur without pain. Consequently, he 
should be ever alert to see that the complication of 
middle-ear inflammation is immediately treated. 

SCARLET FEVER 
PROPHYLAXIS OF SCARLET FEVER 

Every physician, no matter how limited or special- 
ized he may attempt to make his practice, is likely to 
encounter a case of scarlet fever, and to have his 
opinion asked in regard to what should be done to pre- 
vent the transmission of the disease to others. He 
should be able to state promptly, clearly, concisely and 
positively what should be done by the family in which 
the disease occurs to prevent its spread to other indi- 
viduals, what the family which does not have it, but is 
afraid of getting it, should themselves do, as well as 
w T hat they have a right to expect others to do, in order 
to prevent the spread of the disease. 

To the development of sanitary science and preven- 
tive medicine we are indebted for the recognition of 
the fact that scarlatina, scarlet rash and scarlet fever 
are synonymous terms. While scarlet fever may be, 
and often is, a very serious disease with high tempera- 
ture, severe sore throat, intense and widely spread 



CONTAGIOUSNESS OF SCARLET FEVER 75 

eruption, followed by copious desquamation, the fever 
may be slight or entirely absent, the throat may not 
show more than slight congestion, the eruption, if not 
entirely absent, may be not very pronounced in appear- 
ance, not widely spread over the body and of rather 
transient duration, while the desquamation may be so 
slight as to be hardly recognizable. 

Furthermore, it is now generally recognized not only 
that the very mild cases may be followed by the most 
serious sequelae which are observed after the severe 
forms of the disease, and particularly by inflammation 
of the kidneys, but also that severe forms of scarlet 
fever may be, and often are, contracted from patients 
whose symptoms have been exceedingly mild. 

A possible explanation of apparent immunity to 
scarlet fever may be, at least in some cases, that these 
immune individuals have in their earlier life passed 
through an attack of scarlet fever of so mild a type 
that no physician was called to the patient, or if one 
was called, he did not recognize the nature of the dis- 
ease. This, however, probably does not explain all 
cases of apparent immunity. Undoubtedly there are 
many persons who never contract the disease except 
after unusual exposure. On the other hand, it is 
unjustifiable carelessly or wittingly to expose child or 
adult to the disease, no matter how mild the type 
may be. 

CONTAGIOUSNESS 

It was long believed that the contagious element of 
the disease existed in the scales which occur in greater 
or less profusion during desquamation. At present 
there is a tendency to believe that the scales in them- 
selves do not possess the power of transmitting the 
disease. On the other hand, it has not been finally 
proved that the scales are innocuous. Consequently, 
the importance of controlling the dissemination of 
these scales is an open question. 

The belief has been gaining ground that the element 
of contagion exists actively and abundantly in the 
secretions from the throat and nose, and also in the 
discharges from the ear and from the suppurating 
glands when they are present. Also it is believed that 
when the disease is transmitted by dissemination of the 



76 , DISINFECTION IN SCARLET FEVER 

scales, it is due to the fact that the latter have been 
contaminated by these secretions. Obviously then, the 
problem which confronts both family and physician, 
as well as sanitarian, is to control the dissemination of 
these various secretions, discharges, exfoliations, and 
the usual secretions. 

ISOLATION AND DISINFECTION 

The mastery of the problem embraces first, isola- 
tion; second, disinfection. 

The establishment of isolation often taxes severely 
the tact and good judgment of the physician. If the 
family is large and lives in a small house or apartment 
and on a limited income, and if the municipality pos- 
sesses an isolation hospital, or wards of a hospital are 
set apart for the treatment of contagious diseases, the 
easiest way is to transport the patient immediately to 
such an institution. Here he will be under the care 
of attendants who are accustomed to handling patients 
with the disease, and who are trained to exercise all 
the precautions necessary to prevent the spread of the 
disease. Most towns have no special provision for 
taking care of scarlet fever, and in such cases the 
patients must be treated in their own homes. If the 
family has ample means and lives in a large house, a 
large room or a suite of rooms must be set apart for 
the exclusive use of the patient and the special atten- 
dant, who must be secured to give him exclusive atten- 
tion. Such an apartment or suite should, if possible, 
be selected on the third floor of the house or at the 
end of a hall, so that the other members of the family 
will have no occasion to go near it. The room should 
be large and sunny, and all unnecessary articles, such 
as curtains, upholstered furniture, and ornaments, 
should be removed, so that there will be as few articles 
as possible to which the disease poison may adhere 
and which will need to be cleaned or destroyed after 
the recovery of the patient. The attendant should not 
invade other parts of the house. Food and other 
necessities should be left outside the door of the apart- 
ment occupied by the patient by another member of 
the household. Similarly, everything which requires 
removal from the infected apartment should be dis- 
infected and placed outside the apartment, and thence 



FUMIGATION IN SCARLET FEVER 11 

carried away. The most important things which are 
likely to require removal are dishes, clothing, and 
excreta. These should be disinfected by being placed 
in suitable vessels and then allowed to soak for an 
hour in a 2.5 per cent, solution of phenol (carbolic 
acid). Things which are of little or no value and 
which are combustible, such as the remnants of food 
and pieces of cloth or paper which have been used 
about the room, should be burned. If the nurse finds 
it necessary to leave the patient's quarters, she should 
change all her outer garments outside of the patient's 
room, she should cover her hair, and avoid coming 
into close contact with anyone. These precautions of 
isolation should be carried out continuously and 
strictly until desquamation is entirely completed. 
During the period of desquamation the patient should 
be sponged or bathed once or twice a day with hot 
water (and if there are bath-room facilities the con- 
valescent should have a daily hot tub bath), and then 
the skin should be anointed with adeps lanae hydrosus 
(lanolin) which has been softened with almond (or 
other bland) oil, and perfumed to suit. Phenol (car- 
bolic acid) ointments are inadvisable, as any absorp- 
tion would irritate the kidneys. Sponging with alcohol 
is contra-indicated. After desquamation has ceased, 
the patient should remove all the clothing which he 
has been wearing, take a warm bath, with . soap, and 
have his head well shampooed. Then he must dress 
himself throughout in fresh clothing. 

The apartment should be thoroughly disinfected. 

Fumigation after scarlet fever, diphtheria and 
measles does not seem to pay for the cost and trouble 
it causes, and should be abolished. Proper fumigation 
with strong f ormaldehyd, carried out by boards of 
health, should still be done for smallpox and tubercu- 
losis, and perhaps for erysipelas, childbed fever and 
tetanus, especially in hospitals. Spraying with germi- 
cides of all the immediate surroundings of an infected 
patient is the method of disinfection now most satis- 
factory. All washable clothing and bedclothing should 
be boiled : all other clothing should be baked and put 
into the sunlight. Carpets and rugs should be washed 
with antiseptics. Various washing solutions may be 
used, such as chlorinated lime solutions, 5 per cent., 



78 TRANSMISSION OF SCARLET FEVER 

formaldehyd solutions, corrosive sublimate solutions 
1 :500, 5 per cent, phenol (carbolic acid) solutions, or 
better, the higher coal-tar disinfectants, as liquor cre- 
solis compositus. The New York Board of Health 
orders the woodwork and floors scrubbed with hot 
solution of 1 pound of washing soda to 3 gallons of hot 
water. Bedding and night clothing are ordered soaked 
in phenol solutions and then boiled in soapsuds for 
half an hour. Books and toys should be burned. It 
should never be forgotten that outside air and sunlight 
are among the most useful of disinfectants. 

When it is possible to carry out such strict isolation 
as has been described, there is no necessity of quaran- 
tining the rest of the family, but, unfortunately, such 
complete isolation is ideal, and can rarely be carried 
out in actual practice. Even when a large family 
occupies a few rooms, it is essential that one room be 
selected for the patient, and that he be kept in it con- 
stantly, and that the other members of the family be 
kept out of it entirely, except one who is selected to 
act as the attendant, usually the mother. Under such 
conditions it is usually entirely impracticable for the 
attendant to remain constantly in the room with the 
patient. She must frequently leave the room, not only 
to get things which the patient requires, but also to 
perform services for the remainder of the family. 
Under these circumstances it is desirable and often 
entirely practicable that such members of the family 
as attend school, or work in stores or shops should leave 
home, and should live elsewhere for six or eight weeks. 
Those who are obliged to remain at home should avoid 
as much as possible coming into contact with the 
attendant. The latter should have several aprons, 
with sleeves, and large enough to cover all her outer 
clothing. One of these she should wear constantly 
while in the patient's room. Needless to state, she 
should always wash her hands on leaving the room. 

It is generally believed by the medical profession 
that physicians who use even a moderate degree of 
caution rarely transport the disease from a patient 
to another individual, and when this does happen, the 
victim is usually a member of his own family. He 
should endeavor so to arrange his calls that he will not 
go directly from a patient ill with scarlet fever to a 



TREATMENT OF SCARLET FEVER 79 

family in which there is a child. On entering the room 
of such a patient he should put on a long cotton, linen 
or rubber coat. He should avoid sitting on the bed, or 
allowing the bed-clothing to come in contact with his 
own clothing. On leaving the room he should thor- 
oughly wash his hands and dry them on a clean towel 
and remove the gown just outside the patient's door. 

During the convalescence the patient should not be 
allowed to use books from the public library or the 
public school, and should use only such books, maga- 
zines and newspapers as can be burned when he is 
through with them, or when the period of isolation is 
ended. Neither should he be allowed to write and 
send letters through the mail or by messenger to his 
friends. 

Although many practitioners have been in the habit 
of prescribing medicine designed, so they claimed, to 
prevent persons exposed to the disease from contract- 
ing it or developing it, candor compels the statement 
that no drug or any treatment is known which will 
accomplish this result. Although belladonna has been 
extensively used for this purpose, and has been 
believed by many to have accomplished the prevention 
of the disease, there is no adequate reason for believ- 
ing that it has ever produced this result. 

Although often advocated, and sometimes used, the 
impregnation of the atmosphere of the room with anti- 
septics (phenol) and aromatic oils seems to be of no 
value in killing the germs or in hastening recovery. 
Various cresol preparations are recommended for this 
purpose, but their value is small, and the danger of too 
much absorption of phenol vapor causing kidney irri- 
tation is ever present. The fraudulent assertion that 
ozone-producing apparatus prevents the growth and 
dissemination of scarlet fever germs is little less than 
criminal. 

Dogs and cats must be excluded from all patients 
suffering with contagious diseases, and this is espe- 
cially true of scarlet fever. The doors and windows 
must be screened from flies, if it is the season for 
them. 

TREATMENT 

A. Isolation. — Strict isolation measures, already dis- 
cussed under other headings, are most important in 



80 DIET IN SCARLET FEVER 

this disease, and the nurse should distinctly under- 
stand that it is the secretions of the mouth and nose, 
and perhaps suppurating complications, that carry 
infection. The greatest possible care to disinfect or 
sterilize articles contaminated by such secretions 
should be exercised, as the infecting germ is persistent 
and lives for a long time unless killed. The most 
efficient cleanliness of the patient, nurse, and the physi- 
cian who handles the case is also essential. 

B. Diet. — As in the beginning of all diseases, espe- 
cially the infectious diseases, the bowels should be 
thoroughly evacuated with castor-oil, calomel, or what- 
ever the physician deems best; subsequently, they 
should be moved daily by some gentle laxative, found 
efficient. If the patient has diarrhea, it is generally 
caused by a mistake in the diet. Milk is the best 
basis for the diet in scarlet fever. Intestinal indiges- 
tion is not frequent. Foods that add products to the 
blood that during excretion are likely to cause irrita- 
tion of inflamed kidneys should be avoided. The aim 
of the physician should be to diminish the inflamma- 
tion and irritation of the skin, to keep it warm, to 
attempt to keep it moist and promote its secretion, and 
to give a diet rather low in proteins and without meat, 
meat extractives or purins. Also, if possible, no 
drugs should be administered that tend to irritate the 
kidneys, especially after the first week of the illness. 
Such drugs are coal-tar products, synthetic products, 
caffeins, and any of the drugs that are known as 
stimulant diuretics. Even drugs that contain salicylic 
acid should be avoided. 

The greater the intensity of the disease, the more 
liquid the diet should be. While milk is the basis, 
thin cereal gruels are advisable from the start. Malted 
milk may be added to this diet, and lemonade or 
orangeade or oranges, as deemed advisable. Later, 
toasted bread, crackers, and various kinds of cereals, 
and still later, baked potato, rice, corn starch, and 
many other cereal and milk foods, as well as a greater 
variety of fruit, should constitute the diet. 

As soon as the convalescence is established, and 
even before, if the disease is prolonged, a small dose 
of iron should be given daily, as on the above diet 



FEVER IN SCARLET FEVER 81 

the blood cannot get this nutriment. A sugar of iron 
(saccharated oxid of iron) 3-grain tablet should be 
given from one to three times a day. Sodium chlorid 
should always be given a patient from the beginning, 
once or twice a day, in one or more of the feedings. 
If there is a tendency of the nose and throat to bleed, 
or there are hemorrhages in any other part of the 
body, lime-water should be added to the diet. The 
patient should always receive plenty of water. If 
any apparent irritation of the kidneys occurs, it may 
be well to withhold some of the fruits and to tempo- 
rarily diminish the amount of food. 

C. Fever. — If the temperature becomes very high it 
may be advisable to give several doses of an antipy- 
retic, such as acetanilid, antipyrin, or acetphenetidin, 
always bearing in mind the irritant effect of these 
drugs on the kidneys. Hot sponging of the body will 
also tend to reduce the temperature and make the 
patient comfortable. It relieves itching, and many 
times is soothing. Cold sponging in scarlet fever is 
inadvisable and uncalled for. If the fever is excessive, 
tepid sponging may be tried. Restlessness and sleep- 
lessness will also increase the fever, and often a few 
doses of sodium bromid will be of great benefit. It not 
only causes the patient to sleep, but reduces the 
irritability of the peripheral nerves. Also, anything 
that relieves itching or burning of the skin will reduce 
the temperature and the irritability. Quinin is inad- 
visable, as it is excitant to the brain and may tend 
to congest the ears and add one more element that 
may cause middle-ear complications. An ice cap to 
the head, unless actual meningitis is present and the 
hair is clipped close to the scalp, is inadvisable. 
Whether ice caps to the head ever reduce general 
temperature is open to grave doubt. If there is men- 
ingitis, they may relieve the local congestion. We 
doubt if they are ever of much value in general high 
temperature. In this form of treatment the ice cap 
should be applied whenever the patient is sponged 
with cold water. Ice caps, however, tend to fall to 
one side or the other of the head and unnecessarily 
chill the ears, and may become another factor in caus- 
ing middle-ear inflammation. The value of an ice 



82 THE SKIN IN SCARLET FEVER 

bag over the mastoid when it is in danger is not under 
discussion; but an ice cap over an external ear is 
not called for, and may do harm. 

D. Care of the Nose. — Antiseptic, alkaline and 
cleansing gargles and sprays for the throat and nose 
should be freely used and the value of boric acid 
should not be overlooked. The cleaner the nose and 
throat in scarlet fever, the less the secondary infec- 
tion, the less the toxemia, and the less the danger. 
Whatever method is used to clean the nostrils, such 
pressure of the liquid as would tend to force infection 
into one or the other of the sinuses must never occur. 
If there is a purulent discharge from the nostrils, it 
is inadvisable to spray or douche them, as much harm 
can be done from too strenuous or unnecessary treat- 
ment of the nose. 

E. Skin. — Whatever the temperature, hot sponging 
for cleanliness once or twice a day is of advantage, 
is soothing and advisable. Whatever the tempera- 
ture, sponging with alcohol in any form is inadvisable. 
Alcohol, unless the solution is so dilute as to represent 
not alcohol, but only an alcoholic odor, will tend to 
dry the skin, cause more itching, and more discomfort. 
Sometimes sponging with bicarbonate of soda in warm 
water soothes the irritability and stops the itching. 
Powdering with some soothing talcum powder often 
stops itching and quiets the patient. 

As soon as the acute eruption is over and desquama- 
tion is about to begin, the gentle rubbing into the 
skin of some bland oil, as cocoanut oil or almond oil 
or wool-fat, sometimes with little glycerin and water, 
hastens the removal of the dried epithelium, prevents 
scales from flying about (although these scales do 
not carry the contagium) and is very quieting to the 
patient, by preventing the irritation and itching. As 
soon as convalescence is established, a more active 
massage of the skin and muscles is advisable. 

The use of mercuric chlorid or phenol solutions of 
any strength, or phenol ointments, on the skin, is 
inadvisable and inexcusable. Most of these solutions 
tend to dry the skin still more ; the use of phenol 
ointment might result in some absorption and there- 
fore is of danger to the kidneys. Also, as it seems to 



COMPLICATIONS OF SCARLET FEVER 83 

be a fact that the contagium is not spread by the skin, 
there is absolutely no excuse for germicidal ointments 
or applications. 

Unless the temperature is very high and head symp- 
toms are present, it is unnecessary to cut the hair 
close to the scalp. If the scalp itches, as it often does, 
some simple sedative solution may be used. Later, a 
simple gentle shampoo may be given and a little petro- 
latum rubbed into the scalp. A tar soap may stop 
the itching. Oil of eucalyptus has been recommended 
and used as a non-irritant application to the skin and 
scalp. Also, throats have been swabbed with oil of 
eucalyptus preparations, in the belief that eucalyptus 
oil is especially antiseptic in throat contagions. 

F. The Heart. — Cardiac stimulation, especially in 
children, is rarely needed in this disease. The toxin 
of this disease is not as depressant as is that of diph- 
theria, and strychnin is generally inadvisable as it 
causes too much cerebral stimulation, especially in 
children. 

If a long septic process follows scarlet fever, or 
there is later a septicemia, small doses of strychnin 
may be of value, and alcohol is of value as not only 
adding a food, but as tending to prevent a dangerous 
acidemia. Also, in such septic conditions, as much 
carbohydrates should be given as the patient can 
digest. 

If joint complications occur, there is more likely to 
be an endocarditis, and perhaps chorea may develop. 

G. Late Complications. — Middle-ear inflammations 
should be expected and watched for. The drums 
should be early punctured if there is pressure, and the 
services of an expert on diseases of the nose, throat 
and ears should be early sought by the physician, if 
any of these complications occur. 

The glands of the neck are almost always congested 
and enlarged in scarlet fever, and one or more may 
tend to suppurate. It often seems that the local appli- 
cation of a proper-sized ice bag to a gland, if the 
patient will tolerate such an application, aborts serious 
inflammation. However, if such a suspicious gland 
continues to enlarge, the temperature rises and blood 
counts show an increasing leukocytosis, there is prob- 



84 NEPHRITIS IN SCARLET FEVER 

ably pus formation, and the abscess should be soon 
opened. The surgeon, however, often decides that he 
prefers to have warm applications for a short time to 
cause more rapid breaking down of the central suppu- 
rating portion of the gland, so that more complete 
evacuation may occur on incision. The subsequent 
dressings and treatment of such an abscess are purely 
surgical. The temperature will generally drop after 
the evacuation of the pus, unless there is some other 
localized septic process. 

Although the percentage of occurrence of nephritis 
in or following scarlet fever is not great, it occurs 
sufficiently often to be always looked for and expected. 
As above urged, all drugs that irritate the kidneys, 
and all foods that cause irritation should be withheld. 
While it has not been shown that meat will cause 
nephritis, it is not necessary to add meat to the diet 
ii: scarlet fever. Many believe that eggs should not 
be allowed. The withholding of eggs as a preventive 
of nephritis hardly seems necessary. Some physicians 
even withhold salt from the food; this does not seem 
necessary. In giving fluids, patients may be encour- 
aged to take larger quantities by supplementing water 
with citrate solutions or lemonade. This not only aids 
diuresis but may also be of value in reducing acidosis. 
If the amount of urine greatly diminishes and albumin 
appears, there may not be an actual nephritis, but it 
may be well to attempt to forestall or abort such an 
inflammation. Hot packs or applications to the lum- 
bar region can do nothing but good. A general body 
sweat is entirely inadvisable, and the value of profuse 
sweating in uremic conditions is even quite doubtful. 
Perhaps the best preventive of nephritis is prolonged 
rest in bed for at least a week after the fever has 
ceased, as it seems to be a fact that the better the action 
of the skin, the less likely are the kidneys to become 
inflamed, and the skin will be warmer, and is likely to 
be more moist in bed than when the patient is about. 
Pavloantonio (Abstr. The Journal A. M. A., Jan. 10, 
1914, p. 173) found that epinephrin, ten to twenty 
drops per day of 1 : 1000 solution, by mouth, was of 
aid in decreasing albumin and preventing uremia. 
Chilling of the body following scarlet fever is an 
important added cause for the development of nephri- 



CONVALESCENCE IN SCARLET FEVER 85 

tis. Also, if the kidneys have been sufficiently irritated 
to cause a distinct predisposition to nephritis, an 
increased use of the muscles, whether by playing, exer- 
cise, or work, too soon after the acute symptoms are 
over, may so increase the excretory substances from 
muscle metabolism as to add a very tangible factor 
to further irritation of the kidneys and consequent 
nephritis. If nephritis develops, the treatment 
becomes that of acute Bright's disease. 

H. Convalescence. — As just suggested, the patient 
should remain in bed one week after the fever has 
ceased, and the subsequent convalescence should be 
prolonged and carefully watched. During the acute 
stage of the disease the urine should be examined 
daily, to note the first appearance of albumin and how 
long it persists. During the convalescence the urine 
should be examined at least every other day for two 
weeks, and once or twice a week for several weeks 
more. The diet should be increased and most foods 
allowed, except that it may be well for at least two 
weeks not to give meat. During this period the 
patient should continue to receive iron. A simple bit- 
ter tonic may be advisable to stimulate the appetite. 
If the weather is cold and damp, great care must be 
taken that the patient be not exposed. 

Just how long the germ of infection persists in the 
mouth, and especially in the nose, has not been deter- 
mined, but secondary cases can occur when the patient, 
especially if he has a nasal discharge, has been allowed 
to play with other susceptible children. It was long 
thought that the desquamating skin was the cause of 
this late infection of others. 

/. Use of Vaccines. — As it is conceded that strepto- 
coccic infection is concomitant with the cause of many 
of the complications of scarlet fever, vaccine treat- 
ment with stock vaccines or autogenous vaccines has 
been suggested and advised to hasten the eradication 
of left-over septic processes. The same rules and 
regulations, and the same frequency of success will 
doubtless occur in the septic processes following scar- 
let fever as with any other septic process. Vaccines 
have also been prepared of a micrococcus isolated 
from the pharynx — the Micrococcus "S" (Schultze) 



L 



86 WHOOPING COUGH 

— but the results have not warranted the belief that 
this is the specific organism. The use of antistrepto- 
coccus serum in large doses has been mentioned as of 
possible value in extremely septic cases. Also, it may 
be noted that some observers have reported striking 
results following injection of serum obtained from 
convalescent cases. 

WHOOPING COUGH 

THE PROPHYLAXIS OF WHOOPING COUGH 

The greatest mortality of whooping-cough is indirect. 
A large number of those infected die of such complica- 
tions as bronchial pneumonia, capillary bronchitis, 
tuberculosis and a few from hemorrhages, while 
chronic debility, anemia, emphysema, and some lesion 
of the central nervous system are of not infrequent 
occurrence. In young children and infants, whooping- 
cough causes more deaths than measles, and some 
statistics show twice as many deaths as measles ; 95 
per cent, of deaths from whooping-cough occur during 
the first five years of life, and the majority of these 
during the first two years. 

It is pretty well proved that the Bordet-Gengou 
bacillus is the cause of this disease. It seems to be 
established that the greatest infectivity occurs during 
the initial stages of whooping-cough, and that even 
during the active paroxysmal stage there is less lia- 
bility of infection of others, and in the later stages 
there is probably no infective agent present. 

Mallory and Horner confirmed the opinion that the 
Bordet-Gengou bacillus is the cause of the infection of 
whooping-cough. This is a minute bacillus, occurring 
in large numbers among the cilia of the epithelial cells 
of the mucous membrane of the trachea and bronchi. 
It is stated that the germ does not grow above the 
larynx, although of course by coughing it reaches these 
parts. This germ is a small coccobacillus, and resem- 
bles the bacillus of influenza. 

This disease occurs largely in epidemics, and young 
children and babies are apparently most susceptible to 
the disease. This may be more apparent than real 
from two reasons : first, because young children, neces- 
sarily remaining more in the house, are liable more 



PROPHYLAXIS OF WHOOPING COUGH 87 

frequently to come into contact with concentrated 
infected matter if an infected person comes near them, 
and secondly, because a large number of older children 
and the majority of adults have probably had the 
infection and have become immune. However, when 
an adult or elderly person acquires the disease it is 
almost invariably severe. The muscular strength of 
adults makes the paroxysmal coughing of much greater 
danger; they are more liable to emphysema, heart 
strain and hemorrhage. They are not so liable to have 
pneumonic complications. Whooping-cough, however, 
even in adult life, is a not infrequent stimulator of a 
latent tuberculosis. Often an adult, who is in close 
contact with a whooping-cough patient, and who may 
have had the disease in childhood, develops a mild 
form of the disease; at least they have the catarrhal 
symptoms and cough spasmodically occasionally. 
Whether the Bordet-Gengou bacillus is present in 
these cases has not been determined. It is a fact, how- 
ever, that ordinarily one attack of the disease renders 
a person immune. 

The incubation period of pertussis is not definitely 
known, and may vary from two to ten days ; therefore 
before it is considered safe for a child exposed to this 
infection to return to school or to play with other 
children, at least ten days must have elapsed, a,nd 
perhaps a better working rule is two weeks. 

Pathologically, the disease manifests itself by a 
catarrh of the upper bronchial tubes, trachea, larynx 
and perhaps pharynx and nose. The secretion is 
mostly mucus, with perhaps, later, a mucopurulent 
discharge from secondary infections. There are con- 
ditions, moreover, caused by a severe paroxysm of 
coughing, or by a prolongation of these paroxysms, in 
other words, hemorrhages ; perhaps more or less 
emphysema; always cardiac strain, and perhaps car- 
diac dilatation ; and, if frequent or repeated coughing, 
anemia and emaciation. Hemorrhages may occur from 
the nose, in the eyes, or even in the brain. 

The cough is laryngeal in type, is at first dry, and 
later becomes spasmodic and paroxysmal, thus differ- 
ing from that of ordinary colds ; that is, the coughs 
occur in series, more or less periodically, or in showers. 
With these paroxysms there is more or less closing 



88 TREATMENT OF WHOOPING COUGH 

of the larynx, with the attempt at inspiration through 
a narrowed glottis, which causes the characteristic 
whoop. These paroxysms increase in frequency as the 
disease progresses, and are precipitated by any change 
in the atmosphere and by suddenly breathing in cold 
air, as by laughing, and even by swallowing food, and 
they sometimes occur without any apparent cause, 
because of irritation from the germ and its conse- 
quences. The number of paroxysms in twenty-four 
hours varies, but there may be as many as fifty. 
Early in the disease there may be a slight fever. 

TREATMENT 

Unless the patient has considerable rise of tempera- 
ture, it may not be necessary to put him to bed, but, 
especially with children, the paroxysms are generally 
diminished if the child is kept in bed for a time, or at 
least kept quiet. The more active the child, the more 
paroxysms. Consequently, even without fever, if a 
child vomits almost every meal, or if he coughs so 
severely as to cause hemorrhages, or shows that the 
right side of the heart is becoming strained (which is 
the side of the heart most affected), he must be put to 
bed and remain there. 

The actual treatment of this disease may be divided 
into four heads : (1) to prevent the infection of others ; 
(2) to shorten the disease, if possible; (3) to diminish 
the severity of the paroxysms; (4) to treat complica- 
tions as they occur. 

The first indication has already been considered. 

The second indication is met by general hygiene and 
by drugs. Fresh air and sunshine, without exposure, 
are among the greatest mitigators of this disease. If 
the weather is pleasant, the child should be out doors 
or on a veranda most of the time. If the weather is 
such that it is impossible to remain outdoors, he should 
be isolated in one, or better, in two large rooms, so 
that while one room is being thoroughly aired and 
cleansed he may go to the other one. There seems to 
be no question that the more infected or polluted the 
atmosphere of a room, the more the child will cough. 

The Diet. — If the child vomits a meal as soon as 
he has eaten it, during a paroxysm, in a few minutes 



DRUGS IN WHOOPING COUGH 89 

he should be given food again, with the probability 
that the next paroxysm will not so quickly occur but 
that the food may remain in the stomach and be 
digested. A child that receives insufficient nourish- 
ment from any reason should be given food more fre- 
quently. The character of the food should depend on 
his condition, and should be that which is found to be 
less frequently vomited. The best diet is cereal and 
vegetable, with milk and eggs. The end-products of 
meat metabolism are likely to raise the excitability and 
irritability of any one whose nervous system is irri- 
tated. For this reason meat should not be given, and 
no tea or coffee. A patient who is not allowed meat 
should receive a small dose of iron once or twice a 
day. Calcium in any simple form may be used as a 
nervous sedative and a nutrient. Hot baths before 
going to bed relax the nervous system and quiet the 
patient. Also massage is sometimes soothing. Of 
course, it is always essential to have the bowels move 
daily. Plenty of water should be given the child, as 
the more moist the mucous membranes, the less they 
are irritated, and the less frequent the paroxysms. 
For this object many inhalants have been devised. 
Perhaps the most important element of these inhalants, 
whether sprays or steam, is the water that they con- 
tain. Sometimes bland petroleum oils atomized and 
inhaled soothe the irritated mucous membranes. 

Various antiseptics have been suggested. The most 
frequently used is perhaps phenol (carbolic acid) in 
some form, and very popular has been the vaporization 
of a phenol combination in the atmosphere of the 
room. There is no question that phenol tends to 
benumb peripheral nerves. If much phenol was 
absorbed it would disturb the kidneys. Exactly what 
are the germicidal constituents or powers of such 
inhalants has not been determined. Phenol sprays 
have been used in from 0.5 to 1 per cent, strength. 
Antipyrin as a spray and gargle has been much used 
as a germicide in from 5 to 10 per cent, strength, and 
has been much lauded in this disease. Quinin sprays, 
though more disagreeable, have been used in the throat 
as germicides. Various combinations with thymol and 
eucalyptol, and other mild aromatic antiseptics, have 
been used as sprays and gargles or inhalants. It is 



90 VACCINES IN WHOOPING COUGH 

quite probable that a creosote or other antiseptic 
inhalant may inhibit the growth of germs in the 
trachea and upper large bronchi, provided the patient 
is old enough to cooperate and inhale the vapor into the 
lungs to that depth. As an application in the pharynx 
and mouth, hydrogen peroxid solutions, 1 : 5, would be 
as efficient as anything that could be offered. Many 
times, however, these "antiseptic" inhalants or atomi- 
zing substances cause irritation and paroxysms, and 
must be abolished, while mild alkaline solutions, well 
represented by Y\ teaspoonful of sodium chlorid and 
Y\ teaspoonful of sodium bicarbonate in a glass of 
warm water, cleanse and soothe the throat without 
causing paroxysms. 

There are still many who believe that quinin given 
internally will shorten the disease. It has not yet been 
shown that quinin inhibits the growth of the Bordet- 
Gengou bacillus. If there is any tendency to secondary 
infection in the nasopharynx, with congestion of the 
ears, of course quinin should not be given. 

Also, to meet this indication and shorten the disease 
is the vaccine treatment. The exact value of vaccine 
in this disease has not been demonstrated. Hartshorn 
and Moeller examined the reports of 1,445 cases 
treated with vaccines. It is their belief that this 
treatment is worthy of an extensive trial. 

Immunizing doses, to prevent the development of 
the disease in other children of the family, have been 
given in doses of 20 million bacilli, and the dose 
repeated four or more times, and the disease has been 
apparently prevented by such vaccination. More 
recently Hess has made a careful study of the vaccine 
treatment of whooping-cough, and was disappointed 
in this treatment of the disease ; but he did find that in 
a certain percentage of cases immunizing doses pre- 
vented the development of the disease, although this 
prophylaxis was far less efficient than is typhoid vac- 
cine in preventing typhoid fever. Positive conclusions, 
therefore, as to the value of vaccine treatment in 
whooping-cough cannot yet be made. 

The third indication, namely, to diminish the sever- 
ity of the paroxysms, is of great importance. It has 
already been stated that the more quiet the child, the 
less frequent will be the paroxysms. Also, if the child 



ANTIPYRIN IN WHOOPING COUGH 91 

lies down as soon as he begins to cough, he is less likely 
to vomit. An elastic abdominal belt seems to be of 
value in controlling the vomiting and the paroxysms 
of young infants especially. In some patients the 
paroxysms are so severe that chloroform inhalations 
have been given to prevent the intensity of the spasms. 
Also, it has been stated that inhalations of chloroform 
actually lengthen the time between the paroxysms and 
shorten the disease. Chloroform inhalations may act 
as a germicide. On the other hand, the frequent 
administration of chloroform, even in small doses, is 
known to injure both heart and kidneys. 

The most effective of all medicinal treatments, in 
the opinion of several authorities, is antipyrin and 
digitalis. A very good rule for the dosage of antipyrin 
is 0.05 gm. (about 1 grain) for every year of the 
child's age. This should be given three or four times 
a day, depending on the frequency of the paroxysms. 
It should not be continued indefinitely nor used to 
excess. Of course this rule is not applicable for 
higher ages. The frequency should be diminished as 
the frequency of the paroxysms diminishes. Coinci- 
dent with the antipyrin should be given digitalis in the 
form of the tincture, and in the dose proper for the 
child's age, and determined by its effect on the child's 
heart and pulse. The heart needs help, both from the 
strain of the disease and also as antipyrin might cause 
some weakening of the heart. The antipyrin acts by 
causing less irritability of the nervous system and 
relaxing muscle spasm. Even though the drug has 
disadvantages, its disadvantages are much less than 
the harm caused by the whooping-cough paroxysms. 

The bromids have been frequently given and in large 
doses. They act by inhibiting the reflex activity of the 
nervous system and by more or less dulling the periph- 
eral nerves in the throat and upper air passages. 
Chloral has been used in order to depress the nervous 
irritability. Atropin or belladonna have been given in 
large doses, and their value must be in dulling the 
peripheral nerves in the irritated part of the body. 
Atropin is a stimulant, and cannot have any good 
effect in this disease, unless the dose is very large, and 
with such large doses atropin intoxication readily 
occurs, that is, the pulse becomes rapid, the throat dry, 



92 COMPLICATIONS IN WHOOPING COUGH 

the face flushed, and there is likely to be cerebral 
excitation and perhaps dilated pupils. 

Antipyrin is best given to a child in solution, as 
follows : 

Gm. or c.c. 

B Antipyrinae 51 3 iss 

Aquae menthae piperitae. . . 100| AS iv 

M. et Sig. : A teaspoonful, in water, three or four times a 
day. 

This dosage is for a child 5 years old. 

Various hydrotherapeutic measures are often of 
value, and the hot bath is always useful in quieting the 
patient and relieving internal congestions. 

The fourth indication, namely, to treat complications 
as they occur, is almost supererogation, as each com- 
plication calls for its proper treatment. However, 
under this heading the prevention of such complica- 
tions may be urged. Vomiting may be prevented by 
quiet, rest for a while after eating, by the abdomir.il 
belt and by proper food. Nutrition must be kept ap 
at any cost, and, if necessary, the child given simple 
liquid nourishment every three hours. Not infre- 
quently cod-liver oil is well borne and is an oil-nutri- 
ment of great value. Anemia must be prevented by 
iron. If it is seen that the heart is becoming strained, 
and the face and throat remain congested even after 
the paroxysm is over, showing that the right ventricle 
is in trouble, digitalis should be given and such rest as 
would be given any damaged heart. This treatment 
also tends to prevent hemorrhages. Even if the child 
is weak and the circulation is weak, strychnin is inad- 
visable, as it stimulates the nervous system and causes 
or allows more paroxysms to occur. 

If the child has a history of enlarged glands or 
recurrent colds, or has inherited a tendency to tuber- 
culosis, or tuberculosis has been present in the child's 
family, its convalescence after whooping-cough should 
be prolonged, and country or seashore air should be 
urged where possible. Certainly, such a child should 
not be confined in school until its nutrition has become 
as good as before the infection with whooping-cough 
occurred. 



DIPHTHERIA 93 

DIPHTHERIA 

This throat inflammation, now termed diphtheria, 
has been known for centuries, having first appeared in 
the East and later in Europe, occurring mostly in 
epidemics. A carrier of this disease may communi- 
cate it to persons so widely separated as to make the 
occurrence of the disease almost unexplainable by any 
epidemic theory. While nearly all mankind is suscep- 
tible to smallpox, and a large majority to scarlet fever, 
many persons seem naturally immune to diphtheria. 
Also, a closer contact is apparently needed with an 
infected individual than in these other diseases. 

This disease has always had a large percentage of 
deaths; but the death rate since the introduction of 
antitoxin has been constantly on the decrease, and with 
a better understanding of the proper dosage of anti- 
toxin, and with the effort made to diagnose the disease 
early, the death rate will be more rapidly decreased. 
Our best sanitarians believe that for every case of 
diphtheria recognized, at least one sore throat that car- 
ries the Klebs-Loeffier bacillus escapes ; in other words, 
there is an equal number of missed mild cases. 

It has been shown that the normal hydrochloric 
acid in the stomach inhibits or kills the diphtheria 
bacilli; therefore it is exceedingly rare to find these 
germs in the intestines, and very rare to find diph- 
theritic membrane in the stomach. 

In the majority of cases the tonsils, one or both, are 
the parts affected in diphtheria, and with the present 
methods of treatment, in a large portion of these cases 
the membrane will be limited to these regions. The 
soft palate is next most frequently attacked, the 
pharynx next, and nasal diphtheria, with proper care 
taken, is not very frequent. Laryngeal diphtheria is 
not a frequent complication to tonsillar diphtheria; 
it generally begins as the original point of attack. 

CARRIERS 

These may be convalescents from diphtheria, or may 
be those who have had contact with diphtheritic 
patients who may or may not later develop the dis- 
ease, or the term may be perhaps more properly limited 
to those who carry the germ for months. Diphtheria 



94 DIPHTHERIA CARRIERS 

germs may live a long time on books or other sub- 
stances, handled, coughed, sneezed or expectorated 
on by a diphtheria patient, and may infect persons 
coming in close contact with such infected material. 
This method of infection may not be very frequent. 
Animals may carry the infection. It is doubtless 3. 
good axiom to believe that a tonsillitis with exudate 
is diphtheria until it is proved not to contain the 
Klebs-Loeffler bacillus. Such a patient should be 
more or less rigidly isolated, as streptococcic infection 
is, if anything, more readily communicated than is a 
diphtheria infection. Therefore, there can be no 
excuse for not isolating a sore throat with exudate 
or membrane as soon as such a case is discovered. 

The location of the Klebs-Loeffler bacillus in car- 
riers who are convalescing is probably most frequently 
in the throat, though the bacillus may be found in the 
nose. In those who carry these germs long they are 
more likely to be found in the nose. Therefore, 
swabs should be taken of both regions. It is quite 
probable that a surface swab from a tonsil may be 
negative while a culture obtained from probing into 
crypts of the tonsils or in the region back of the tonsil 
might show the presence of the germ. It is culpable 
neglect to fail to examine a patient thoroughly to 
ascertain if he is free from the Klebs-Loeffler bacillus. 

The boards of health vary as to the number of nega- 
tive cultures that will release a patient from quaran- 
tine. The safest number is perhaps four negative cul- 
tures, two from the throat and tonsils, one from crypts 
or back of the tonsil, and one from the nose, taken on 
alternate days, at a considerable interval from the use 
of any antiseptic washes, gargles or sprays. This 
would seem to prove that a patient was free from the 
Klebs-Loeffler bacillus. 

TREATMENT OF CARRIERS 

Various methods of ridding a carrier of the diph- 
theria germs have been tried. Local measures vary, 
and may comprise painting the suspected regions with 
tincture of iodin or with Lugol's solution, with silver 
solutions, phenol solutions, or the use of various gar- 
gles, hydrogen peroxid solutions, etc., and the nasal 
inhalation of various thymol or iodin inhalants or 



TREATMENT OF DIPHTHERIA CARRIERS 95 

sprays. There is no question that whatever else is 
done, some local antiseptic should be applied. Diph- 
theria antitoxin injection has not been very success- 
ful. Local applications in the mouth, throat or nose 
of antidiphtheritic serum have not been proved to be 
very successful. Vaccinations with dead diphtheria 
bacilli have been only partially successful. These 
various methods are described by Albert. He believes 
that a local application to suspicious crypts of the 
tonsils of a "5 per cent, solution of silver nitrate 
will destroy all bacteria with which it comes in con- 
tact." A thorough application of a 10 per cent, solu- 
tion of silver nitrate he finds will cause some destruc- 
tion of the epithelium of a crypt and a fibroblastic 
proliferation with ultimate obliteration of the lumen, 
which is of course the object desired. 

Very successful treatment of diphtheria carriers 
seems to be spraying the nose and throat with pure 
cultures of Staphylococcus pyogenes aureus. This 
spray is apparently harmless to the individual although 
reports of severe infections have been published. This 
method was first used by Schijzftz, in 1909. Although 
it is not always efficient, in some instances it has 
removed the Klebs-Loeffier bacillus and prevented its 
growth so that cultures were negative to it in a week 
or less. It has not proved very successful in nasal 
cases. On the other hand, Womer, after using this 
staphylococcus spray in forty-two cases of diphtheria 
carriers, comes to the conclusion that although it is 
harmless, it does not appreciably lessen the period of 
quarantine. This leaves the value of this treatment 
still subject to positive proof. It may certainly be 
tried. 

Wood thinks that in one or two instances, in diph- 
theria, spraying the affected areas with live lactic acid 
bacilli hastened the disappearance of the diphtheritic 
germ. Antiseptics should not immediately be used in 
the throat after such spraying, as he thinks it is the 
live bacilli that act perniciously on the diphtheria bacil- 
lus. This suggestion is worthy of further investigation. 

Miller recommends that diphtheria carriers have 
their throats sprayed with warm f ormaldehyd solutions 
every three or four hours during the daytime. The 
strength which he recommends to begin with is 0.25 



96 KAOLIN FOR DIPHTHERIA CARRIERS 

or 0.5 per cent, in water of a 40 per cent, formaldehyd 
solution. [The official Liquor Formaldehydi is a 37 
per cent, solution.] This solution may be increased in 
strength to 1 per cent, if deemed advisable. He found 
that in from three to six days the diphtheria bacilli 
disappear from the throats of carriers thus treated. 
He urges that the solution be prepared fresh each day. 
He did not find that the kidneys were irritated by such 
treatment. 

Hektoen and Rappaport (Jour. A. M. A., June 12, 
1915, p. 1985) have found that, when properly applied, 
kaolin in the form of a dry powder removes not only 
diphtheria bacilli, but also practically all bacteria from 
the nose in the course of from three to four days. 
For this purpose the kaolin is blown into the nose six 
or seven times a day at two-hour intervals by means of 
a rubber bulb attached to a glass tube, the free end of 
which tapers a little. The insufflation is repeated sev- 
eral times at each treatment. The success of this treat- 
ment appears to depend largely on the free and thor- 
ough distribution of kaolin over the nasal surfaces. 
In cases of more or less obstruction of the nasal pas- 
sages, the removal of bacteria by insufflation is more 
difficult. 

In order to secure the most thorough application of 
kaolin to the mucous membrane of the throat, patients, 
if old enough, are instructed to swallow as slowly as 
possible one-third teaspoonful of kaolin four or five 
times an hour during the day. In the case of adults 
and older children who are anxious to get rid of 
diphtheria bacilli, this method, which has been selected 
after trial of several others, involves no special diffi- 
culty. In the case of small children, it is more difficult 
to apply enough kaolin, and the plan of mixing the kao- 
lin with sugar in the form of tablets is being consid- 
ered. In a number of cases, in some of which there 
were a great many diphtheria bacilli in the throat, com- 
plete and apparently permanent removal has been 
accomplished by means of kaolin in the way described 
in from two to four days, the throat to a large extent 
beiljg freed from all bacteria. 

They have found also that the insufflation of kaolin 
into the nose in cases of rhinitis in scarlet fever appears 



IMMUNITY TO DIPHTHERIA 97 

to improve the condition rapidly and to remove strep- 
tococci and other bacteria quite promptly. 

They have not found kaolin to be irritative; when 
taken into the mouth it gives rise to a feeling of 
grittiness. 

It seems, then, that kaolin, and probably also other 
substances of a similar nature, may prove of value in 
removing bacteria from various surfaces of the body by 
virtue of mechanical adsorption. This may prove of 
advantage, not only in carriers, but also in conditions 
of acute infection. 

IMMUNITY 

While it has been long known that infants and many 
adults seem not to be susceptible to diphtheria, it has 
only lately been shown that probably a large propor- 
tion of adults, stated at 90 per cent., perhaps 50 per 
cent, of children, and perhaps 80 per cent, of new- 
born infants have diphtheria antitoxin in their blood 
and are not likely to become ill with diphtheria. 

A skin test has been devised, known as the Schick 
reaction, to determine whether or not an individual 
is protected against diphtheria, that is, whether he has 
diphtheria antitoxin in his blood. The reaction seems 
very positive, and distinctly shows that an indi- 
vidual is artificially protected or has natural antitoxin 
against this disease. The test is made with a dilute 
diphtheria toxin of such strength that 0.1 c.c. contains 
one-fiftieth of the minimum fatal dose for a guinea- 
pig. This amount, namely, 0.1 c.c, is injected into the 
layers of the skin, perhaps best on the inner surface 
of the arm. A positive reaction should appear in from 
twenty-four to forty-eight hours, and is evidenced by a 
slight swelling and localized redness, a reddened papule 
which remains from seven to ten days. When this 
papule disappears, the skin over it may desquamate 
slightly, and pigmentation may remain for days and 
even weeks. Park states that the injection is best given 
with a small hypodermic syringe with a platinum point 
needle, that the injection must be into the skin and not 
subcutaneously, and that immediately after the injec- 
tion there should be a raised w r hitish spot, which in 
twenty-four hours becomes bluish, with a slight edema. 
Schick's interpretation of the positive reaction, as just 



98 TREATMENT OF DIPHTHERIA 

described, is that the patient has no antitoxin in his 
blood, or at least less than 1/30 unit of antitoxin in 
1 c.c. of blood. He declares that all persons so react- 
ing are susceptible to diphtheria, and Park agree with 
him. Park, in his summary on immunity in diph- 
theria, states that according to Hahn the interval 
between the injection of vaccine and the development 
of antitoxin is not less than three weeks, while other 
investigators think that it may be eight days. Persons 
who have a natural antitoxin show an earlier increased 
antitoxin production. Von Behring considers that 0.01 
unit of antitoxin per 1 c.c. of blood is sufficient to pro- 
tect a healthy individual, and much less may protect 
against diphtheria. 

Immunizing doses of antitoxin to persons who have 
been exposed to diphtheria, given early, are generally 
successful in preventing the development of the dis- 
ease. The immunizing dose for a child should prob- 
ably be at least 1,000 units. Doubtless adults should 
receive larger doses. 

TREATMENT 

A. Isolation. — It should be again urged that a throat 
with spots or membrane should be considered as likely 
to be diphtheritic until a culture has proved it not to be. 
Such a patient should be isolated in the best room 
available, looking toward the possibility of the dis- 
ease being diphtheria and a nurse being required. 
Other children of the family must be excluded from 
contact with this patient. If the case is clinically one 
of follicular tonsillitis, the physician may wait for a 
positive test before giving antitoxin. If, however, the 
case is clinically diphtheria, antitoxin should be given 
without a report being waited for, provided there is 
nothing in the history of the patient to show that 
there will be any hypersusceptibility to horse serum. 
Whether it is follicular tonsillitis, or other strepto- 
coccic infection, or diphtheria proper, gargles and 
local cleanliness of the throat should be immediately 
inaugurated, and when this is properly carried out, 
the danger of infection of others is reduced to a 
minimum. 

It is hardly necessary in this day, in which the 
advisability of sunlight, a large room, an adjacent 



GENERAL CARE IN DIPHTHERIA 99 

bathroom, the absence of all unnecessary draperies, 
furnishings, rugs, etc., for a proper isolation room are 
so well understood, to describe the needs in detail. 
Instruction should be given the family in the minor 
details of the prevention of infection of others. A 
properly trained nurse well understands the necessity 
for burning wooden tongue depressors, wooden swabs, 
the gauze and cotton used around the patient's nose 
and mouth, and washcloths; the use of liquid soap; 
simple but effective cleanliness of the patient's face, 
hands, and body; boiling of all eating and drinking 
utensils; disinfecting the toothbrush with non-poison- 
ous germicides; allowing the bed clothing and bed 
garments to stand in germicidal solutions before being 
sent to the wash ; frequent washing of her own hands 
in germicidal solutions ; and gargling her own throat 
with hydrogen peroxid solutions. These are all sub- 
jects of general knowledge by physicians and nurses. 

B. General Care of Patient. — High fever is not fre- 
quent in diphtheria, unless the case has been neglected. 
Consequently, the patient should receive, almost from 
the beginning plenty of nutritious food. The exact 
diet, of course, depends on the age of the patient. 
Milk, oatmeal gruel, eggs, meat juice well salted, toast, 
butter, and the whole, or the juice, of one or two 
oranges, would represent the food needed. With or 
without meat, it is well to give a diphtheria patient 
iron, and no preparation is better than the tincture of 
iron chlorid in 5-drop doses, three times a day, given 
in fresh lemonade or orangeade, after nourishment. 

However well the gastric juice inhibits the growth 
of the bacteria, it is always wise for a patient to gar- 
gle, or be sprayed, before taking food, so that the 
mouth and throat will be as clean as possible. 

The bowels should be moved daily by some simple 
laxative, if they do not move without such help. 

While a diphtheria patient should have plenty of 
fresh air and all the sunlight possible, he should be 
kept warm. He should not be allowed to become 
chilled, as the toxins of this disease cause depression 
and the patient's temperature may be quite low, and 
the hands and feet easily become cold. Even if the 
temperature is high, the bathing should be by warrn 
sponge bath. 



100 ANTITOXIN IN DIPHTHERIA 

C. Antitoxin. — Recent investigations by Schick 
show that the dose of antitoxin advisable for ordinary 
cases of diphtheria can be based on the weight of the 
individual. Schick finds that 100 units of antitoxin 
per kilogram of weight is sufficient to combat the toxin 
in diphtheria in all ordinary cases, and in severe cases 
500 units per kilogram is more than sufficient. In 
other words, enormous doses of antitoxin are not 
needed, which has long been the belief of Park of 
New York. This is especially true if the antitoxin is 
given early. A kilogram equals 2 1/5 pounds avoirdu- 
pois, and a child weighing 45 pounds, in an ordinary 
case of diphtheria, should be given 2,000 units of 
antitoxin ; while if the case is severe, or in nasopharyn- 
geal or laryngeal types, 10,000 units would be all 
sufficient. By the same method of decision as to the 
dose, an adult of about 130 pounds should receive 
6,000 units in a mild case, and 30,000 units if the 
diphtheria is of malignant type, or has affected parts 
where the danger of absorption is greater. 

It seems quite probable that if such doses can be 
administered on the first day of the infection with the 
Klebs-Loeffier bacillus, no more antitoxin will be 
needed in such cases, and that death from this disease 
will be reduced to a minimum. 

Smith and Park have shown that when antitoxin 
is given subcutaneously, it takes from three to four 
days before the maximum amount of antitoxin is cir- 
culating in the blood. If the antitoxin is given intra- 
muscularly this period is shortened. From these find- 
ings, therefore, the conclusion should be made that 
if the case is urgent and the toxemia serious, anti- 
toxin should be administered intravenously; if the 
case is severe and the diagnosis has not been made 
early, antitoxin should be given intramuscularly; in 
ordinary or mild cases, and on the first day or two of 
the disease, it may be administered subcutaneously. 

D. Care of the Throat. — It would be just as sensible 
to perform a major operation with the most perfect 
technic and yet take no means whatever of preventing 
infection, as it is to administer antitoxin in proper 
dose in diphtheria and then to take no proper care of 
the throat. All odor and all danger of secondarv 



CARE OF THROAT IN DIPHTHERIA 101 

infection are removed by proper treatment of the part 
affected. Although germicides cannot kill the germs 
deep in the mucous membrane, or those that are pro- 
tected by an overlying exudate, a certain large por- 
tion of the surface bacteria are surely killed by as 
simple a gargle as hydrogen peroxid solution. More 
active and more irritant germicidal gargles or germi- 
cides that are sources of danger when swallowed, are 
entirely unnecessary in diphtheria. 

If the child is old enough to gargle or swash the 
tonsils, this is the best method of cleansing the throat. 
If the child is not old enough, thorough spraying of 
the throat should be done. A solution of one part of 
the official Aqua Hydrogenii Dioxidi to 3 parts of 
warm water, freshly prepared each time, should be 
used as a gargle, every one and one-half or two hours 
during the day, and every three hours during the 
night. Three or four minutes after this gargle has 
been used, it should be followed by some simple alka- 
line wash, to remove the irritant effects of the hydro- 
gen peroxid. A gargle that may be used for the sec- 
ondary cleansing purpose is a teaspoonful of boric 
acid added to y 2 glass of warm water. This will not 
all dissolve, but will deposit on the throat and act 
as a mild antiseptic. Also, there is no greater pro- 
moter of mucous secretion of the throat than boric 
acid ; and the more the mucus is secreted, the quicker 
will the membrane be loosened. Or, a simple solution 
of J4 teaspoonful of salt and Y\ teaspoonful of sodium 
bicarbonate may be added to y 2 glass of warm water. 
The object of such a gargle and wash is to cleanse the 
mouth and throat of froth and pieces of membrane, 
mucus, mucopus, etc., and to soothe the membrane. 
It is frequently advisable to insufflate boric acid 
directly on the masses of membrane or exudate. This 
should be done by the physician. 

After the throat has been cleansed all that is pos- 
sible, it is often of value to apply tincture of iodin to 
the membrane or exudate. Care must be taken not to 
touch the healthy membrane with this solution. 
Lugol's solution may be applied to the parts of the 
throat that are not affected, which often tends to pre- 
vent development of more exudate or membrane. If 
there are pockets and crypts in diseased tonsils, after 



102 GENERAL MEDICATION IN DIPHTHERIA 

cleansing such, boroglycerid may be applied to heal 
and to prevent spreading of infection. 

As frequent gargling is very tiresome for the throat, 
swashing is nearly, if not quite, as efficient, and should 
be suggested. If the child is too young to gargle or 
swash, the peroxid should be sprayed on, and the 
solutions for this purpose should be stronger, namely, 
1 part to 2 parts of warm water. The cleansing spray 
may be used afterward. If the throat and mouth gen- 
erally are irritated, a soothing gargle is as follows : 

Gm. or c.c. 

B Acidi borici 2 gr. xxx 

Potassii chloratis 5 3 iss 

Aquae menthae piperitae 200 AS vii 

M. Sig. : Use undiluted as a gargle, as directed. 

Of course, any other flavor than peppermint could 
be used in this mixture. 

Whether or not it is advisable to use a w r eak hydro- 
gen peroxid solution in nasal diphtheria is a question 
for individual decision of the physician; generally it 
is too irritant, even when used weak, and is inadvis- 
able. Cleansing mild alkaline solutions or boric acid 
solutions represent the most successful treatment of 
nasal diphtheria used as sprays or snuffed through 
the nostrils. Such mild, warm solutions may be poured 
from a small vial or from a teaspoon into the nostril, 
with the head thrown back. It is inadvisable to use 
any of the douches that are on the market, or any 
syphon douche, as the pressure is too great, and fluid 
is often forced up the eustachian tube or into some of 
the sinuses. Suprarenal extract may be added to 
these solutions, if deemed advisable, but it should not 
be used too frequently. Also, the nose should not be 
sprayed too frequently. 

As soon as the throat is clean, the frequency of the 
gargles should be diminished, but it should be several 
days before the patient is not awakened at night to 
gargle at least once, or better, twice. 

The treatment of the throat advised for diphtheria 
is equally applicable to follicular tonsillitis or scarla- 
tinal throats, and to septic sore throat. 

E. General Medication. — A diphtheria patient 
requires very little general medication, unless some 



THE HEART IN DIPHTHERIA 103 

complications occur. In the beginning a small dose of 
calomel, or a dose of castor oil may be advisable, and 
subsequently whatever simple laxative is needed to 
cause a daily movement of the bowels. The tempera- 
ture does not often call for treatment. If it is high, 
or there is headache and backache and general aches, 
two or three small doses of a coal-tar antipyretic may 
be given. The following combination for a child not 
under 10 years old is efficient: 

Gm. 

R Acetphenetidini 1 1 

Phenylis salicylatis 1 j aa gr. xv 

M. et fac chartulas v. 

Sig. : A powder every three hours, if needed. 

Later, if the temperature is high, tepid sponging is 
sufficient, but generally, with the ordinary low tem- 
perature of diphtheria, hot sponging for cleanliness 
and to increase the activity of the skin, and to remove 
the perspiration, should be done once or twice daily. 

As suggested above, every patient with diphtheria 
should receive iron, either the tincture of iron chlorid, 
a few drops in fresh lemonade, or a 3-grain tablet of 
eisenzucker, three times a day, or 0.10 gm. (1^4 
grains) of reduced iron, in capsule, three times a day. 
If there is a tendency for the throat or nose to bleed, 
it can do no harm to add lime water to the diet, and it 
may be of value. 

On account of the nervous depression caused by the 
toxins of the Klebs-Loeffler bacillus, a small dose of 
strychnin, not exactly as a cardiac stimulant, but more 
as a nervous stimulant, is advisable, provided the con- 
dition of the patient seems to require it. For a child 
10 years old, 1/60 grain of strychnin sulphate, once in 
six hours, is generally a sufficient dose. If the child 
is made nervous by strychnin, it should certainly be 
withheld. A little coffee or tea may be given a child, 
as a medicine for the action of the caffein, and is of 
value. 

F. Care of the Heart. — Although it was long con- 
sidered that heart failure in diphtheria was due to 
vasomotor paralysis, or to action on the vasomotor 
center, it has been shown by Porter and Pratt that 
such is probably not the case: that heart failure is 
probably due to the action of the toxins on the heart 



104 CARDIAC WEAKNESS IN DIPHTHERIA 

itself. Dr. F. W. White of Boston long ago showed 
that the heart was frequently affected more or less 
seriously in diphtheria. White also quotes many other 
authorities showing that myocarditis is not an infre- 
quent complication, that valvular disease may occur 
from diphtheria, and that even a chronic myocarditis 
may persist, or a valvular lesion may continue for 
months or even years, or for life. The mitral valve 
is the one most frequently diseased, and if a lesion is 
caused, it is generally insufficiency. About 60 per 
cent, of the patients with diphtheria show an irregular 
pulse, and the younger the patient, the more liable he 
is to have this heart irregularity. It may occur even 
in mild cases. The murmur at the apex is doubtless 
due to a relative insufficiency of the mitral valve, 
because of slight dilatation of the left ventricle. In 
this investigation, necropsies showed that endocardi- 
tis and pericarditis are extremely rare complications 
in diphtheria. 

Clinically, the gallop rhythm, with or without vomit- 
ing and epigastric pain and tenderness, is a bad symp- 
tom in diphtheria. This gallop rhythm of the heart 
is very serious, and if accompanied by vomiting, the 
prognosis is very bad. Hume and Clegg, after an 
investigation of 573 cases of diphtheria, declare that 
any form of arrhythmia of the heart (except sinus 
arrhythmia) in diphtheria indicates that the heart mus- 
cle or nerves are pathologically disturbed. This may 
occur even when the diphtheria is apparently mild. 

After a patient is apparently well from diphtheria, 
if he has been severely ill, and especially if the case 
has been neglected and a large amount of toxins have 
been absorbed, cardiac failure may occur any time 
from the second to the fifth week. Symptoms of late 
cardiac weakness are often a slow, weak pulse. Such 
hearts, however, become rapid on the least exertion. 
Such patients are often very pale, and there are liable 
to be more or less gastro-intestinal disturbances. 

There can be no question that the effects on the heart 
in diphtheria are due to the Klebs-Loeffler bacillus 
toxins ; consequently, if antitoxin in sufficient dose is 
given early, the toxic effect on the heart will probably 
rarely occur. Consequently, cardiac deaths in diph- 



PARALYSIS IN DIPHTHERIA 105 

theria will be less frequent with the early proper 
administration of antitoxin. 

The most important treatment of cardiac complica- 
tion is rest, and prolonged rest. A patient who has 
shown cardiac inflammation of any kind, or cardiac 
irritation during diphtheria, should have a prolonged 
rest in bed and a very slow convalescence. The small 
dose of strychnin suggested above as a nerve stimulant 
is probably sufficient. If the heart is very rapid, it 
may be unwise to give even this small dose. Larger 
doses do not seem to raise the blood pressure during 
illness, and strychnin in large doses as a cardiac tonic, 
in prolonged weakness, is not so successful as has been 
thought. In an apparently acute failure, a fair-sized 
dose, 1/40 grain for a child 10 years old, may be given 
hypodermically ; but to persist in large doses of strych- 
nin is inadvisable. Digitalis is not indicated, and alco- 
hol should not be given. Caffein and camphor may be 
worth while ; but the main thing is absolute rest, small 
amounts of food, the least possible disturbance for 
bathing, feeding, defecation and urination, and no 
prostrating purgatives. 

G. After Rest. — A patient who has recovered from 
diphtheria, however mild it may have been, should 
have, for the first two weeks, at least, a carefully 
watched convalescence. Strenuous exercise should be 
avoided, and the heart should be carefully examined 
before the patient is allowed to return to his usual 
work, school, or play. 

H. Paralysis. — With the early injection of a suffi- 
cient dose of antitoxin, diphtheria paralysis will 
become less and less frequent. The paralysis of the 
soft palate, which used to be so frequent, is already 
becoming infrequent. This paralysis occurs early, 
between ten and twenty days from the beginning of 
the illness. The treatment consists of tonics, small 
doses of strychnin, the best of nutrition, fresh air, 
sunlight, rest, and prolonged convalescence. The gen- 
eral paralyses, which are now rarely seen, were more 
serious, and occurred later. They are slow in recov- 
ery, and besides general treatment, require massage 
and electricity. 



106 LARYNGEAL DIPHTHERIA 

/. Diseased Tonsils. — Quite probably diseased ton- 
sils cause a susceptibility to diphtheria, as they cer- 
tainly do to follicular tonsillitis. After complete 
recovery from a diphtheria attack, when the general 
condition is perfect, and the heart is in good condition, 
operations should remove all portions of tonsils that 
show disease. Whether complete enucleation should 
be done, or only diseased portions should be removed, 
and whether or not the capsules should be left, are 
subjects for an expert decision. 

LARYNGEAL DIPHTHERIA 

Membranous croup is laryngeal diphtheria, and as 
soon as the diagnosis can be made that there is exu- 
date in the larynx or laryngeal region, antitoxin should 
be given in large dose, without waiting for a decision 
from the laboratory that the Klebs-Loeffler bacillus is 
present. The only safe place for a patient with 
laryngeal diphtheria is a contagious disease hospital, 
where expert skill in intubation and, if necessary, in 
tracheotomy can be quickly obtained. The main dan- 
ger from diphtheria in this location is suffocation. 

The toxemia is not great, and the absorption is much 
less than in nasal, nasopharyngeal, or even in tonsillar 
diphtheria. 

The best of nutrition is important, as exhaustion 
from labored breathing is likely to occur. The atmo- 
sphere of the room is better moist, on account of the 
membrane becoming dry and causing more obstruc- 
tion before it loosens and is coughed up. Just how 
much local steaming of the throat, or inhalation of 
various medicated solutions should be given, is to be 
decided by the individual physician. The main advan- 
tage is doubtless from the vapor of water. 

The main requirements to be remembered in laryn- 
geal diphtheria are the administration of an immediate 
large dose of antitoxin ; intubation by a skilled operator 
as soon as indicated ; a trained nurse skilled in intuba- 
tion cases, if such can be obtained ; the ability to recall 
quickly the physician who intubated if the tube is 
coughed up; the immediate removal by the nurse of 
the intubation tube if it plugs up, and the quick per- 
formance of tracheotomy by the surgeon, if such a 
measure is needed. 



SEPTIC SORE THROAT 107 

SEPTIC SORE THROAT 

For some years there have been reported in England 
epidemics of septic sore throat, some of which have 
been distinctly traced to infected milk, and all of 
which probably develop from that source. In the last 
few years several cities and towns in this country have 
suffered from epidemics of this character, and in 
every instance it has been traced to milk from one 
dairy, and ultimately to one or more diseased cows. 
The disease that causes such infection is an inflamma- 
tion of the milk glands, a mastitis, or an inflammation 
of the udder termed garget. Another possible source 
for the dissemination of this germ is an infected throat 
of the milker, or of some one who handles the raw 
milk. 

The germs found in the inflamed udders, in the raw 
milk, and in the throats of those infected are the same, 
namely, the Streptococcus pyogenes. 

The clinical symptoms have been the same in all of 
these epidemics, and Capps states that the throats 
generally show intense hyperemia without a grayish 
exudate. The cervical lymph glands enlarge, and may 
suppurate ; there is extreme prostration, and a tendency 
to relapse. The complications are inflammation of the 
middle ear, abscess around or about the tonsils, and 
erysipelas or other skin eruptions. The most danger- 
ous and fatal complication is peritonitis, and there may 
be fatal septicemia, with localization in the lungs. 
Endocarditis, myocarditis, arthritis, and nephritis may 
occur as complications in this septic process. 

Means of prevention of septic sore throat in epi- 
demics must include a more frequent bacteriologic 
examination of the udders of cows and of the throats 
of those who handle raw milk. Pasteurization of milk 
would prevent these germs from causing infection. 

The treatment of these septic sore throats is not 
different from that of follicular tonsillitis, namely, 
dilute hydrogen peroxid solutions 1 : 4, immediate sub- 
sequent washings with mild alkaline cleansing solu- 
tions, and the local application of a weak iodin solu- 
tion, as Lugol's solution (too strong iodin prepara- 
tions might increase the swelling and hyperemia of 
the throat). 



108 GERMAN MEASLES 

On account of the prostration, the patient should 
receive plenty of nutriment. The bowels should be 
moved daily. Pain should be stopped, if it is trouble- 
some, by codein or morphin, if deemed advisable. 
High temperature should be treated as seems best, and 
the complications combated as they occur. Infection 
of others is prevented by the same methods as those 
described for diphtheria. The blood in this disease 
should be studied, not only to determine the amount of 
leukocytosis, and the type that is probably present, 
but also to determine the amount that gives a favor- 
able prognosis. Such studies may give a clue as to the 
possible value of an autogenous vaccine. 

GERMAN MEASLES 

This is a highly contagious germ disease, most fre- 
quently affecting children and youth. It generally 
occurs in epidemics, but a considerable number of 
persons exposed to the disease do not acquire it. 
While the germ has not been discovered, and though 
it is not known just how it is transmitted, the proba- 
bility is that the secretions of the nose and throat are 
the means of spreading the infection. It is doubtful 
if the eruption or the desquamating epithelium carries 
the contagium. The stage of incubation is apparently 
long, averaging perhaps from about ten days to two 
weeks. The stage of invasion is rarely seen, as when 
it is first realized that the patient is ill, the eruption 
is present. The eruption is a maculopapular one, 
reddish, and rarely confluent. The papules are less 
raised than in measles ; in fact, many points of erup- 
tion are purely macules. The color is brighter than 
that of measles. It occurs first on the chest and 
face, and then gradually spreads over the body, dur- 
ing the first twenty-four hours. Questioning of the 
person attacked often shows that there were slight 
rigors and some backache or headache or feelings of 
indisposition. The temperature is generally slight, 
rarely above 100 F. 

Complications are rare, and although the patient 
should be confined to the house, the infection is sim- 
ple, and there are not likely to be any consequences. 

This disease requires, ordinarily, no real treatment. 
Simple cathartics should be given, the diet reduced, 



CHICKEN-POX 109 

and the patient kept indoors until the eruption has 
disappeared. If the throat is irritated, an alkaline 
gargle should be used. The usual simple methods of 
preventing the infection of others should be car- 
ried out. 

The disease should be made reportable, as it is so 
often confused with regular measles, and rarely has 
been confused with mild scarlet fever. It is more 
likely to be confounded with various kinds of intes- 
tinal or food poisonings that cause eruption. 

CHICKEN-POX; VARICELLA 

This simple, acute, contagious disease, generally 
very mild, and rarely requiring any medication or 
treatment, need not be mentioned here except that 
it is frequently confused with smallpox. 

In chicken-pox: The incubation period is at least 
two weeks. There is no definite history of a pre- 
vious attack of this disease. A history of successful 
vaccination within a few years, or a definite history 
of a previous smallpox causes presumption that the 
disease is chicken-pox. There is usually no history 
of a stage of illness before the eruptive stage. The 
eruption appears in the first twenty-four hours of the 
disease, beginning on the back, chest or face, and 
is most profuse on parts of the skin covered by cloth- 
ing. The eruption appears in successive crops on 
successive or alternate days, so that various stages of 
the lesions may be present at one time. The lesions 
are round and oval, and the margins are not crenated. 
The eruption passes through the following stages : 
1. Macules lasting a few hours. 2. Soft, superficial 
papules lasting a few hours. 3. Clear, thin-walled, 
tense vesicles each lasting a few hours (these vesicles 
may be readily broken and appear cupped or pitted, 
and the weeping vesicle then quickly becomes crusted). 
4. The crusts, lasting a shorter or longer time, depend- 
ing on the treatment (each crop completes its cycle 
from macule to crust in from two to four days). 
5- Pitting may occur, but the pits are few, superficial, 
and often oval. 

It is essential that chicken-pox cases should be early 
diagnosed, and that the patient should be isolated. A 
laxative should be given ; the diet should be simple 



110 MUMPS 

and without meat; warm baths, and powder to pre- 
vent itching, represent the only treatment generally 
required. Older patients should be cautioned, and 
children should be prevented from picking open the 
vesicles that occur on the face, thus preventing pit- 
ting. Young children should wear celluloid mittens. 

MUMPS 

This is a highly infectious disease, with a long period 
of incubation, from two to three weeks. There is 
more or less of it always present in most cities, and 
there are likely to be epidemics of it in certain seasons 
of the year, more particularly, perhaps, in the spring 
and fall. Children and youth, especially boys and 
young men, are the most susceptible to it. Infants and 
adults are not so likely to have it. Possibly adults are 
less likely to have it because they have been rendered 
immune by unrecognized mild attacks in childhood. 

While the typical localization of this infection is in 
one or both parotid glands, the submaxillary glands 
may be coincidently involved, or may be the only 
glands involved. As simple and harmless as this dis- 
ease generally is, it may cause very high temperature, 
sudden cardiac failure, and frequently in young boys 
and male adults a complication, or metastasis, of 
orchitis, which is always serious. In girls the mam- 
mary glands or the ovaries may show metastatic 
inflammation. 

A patient with the disease should generally be 
isolated, and the attack will often be milder if the 
patient remains in bed. Although the disease can be 
serious, it is generally so mild in children that it is 
sometimes a question whether other children of the 
same family should not be allowed to contract it, for 
the reason that one attack generally confers immunity 
for all time, and the disease is much more serious in 
adults, especially in young men, than in children. Of 
course, an infected child, even though very mildly 
sick, is immediately sent home from school. On the 
other hand, doubtless not a few children with very 
mild cases are unwittingly allowed to remain at school. 



MUMPS 111 



TREATMENT 



The disease is so mild that it may not require any 
special treatment. Pain in the infected glands is 
rarely severe, and is modified by dry warmth or simple 
absorbent-cotton applications, and by any oily appli- 
cation, the latter to relax the tension of the skin over 
the swollen gland. For this purpose olive oil may 
be used, or petrolatum, or an ointment may be made 
with 10 per cent, methyl salicylate in petrolatum. It 
is inadvisable to use ice or cold applications to the 
parotid glands in mumps. 

The diet should be mild, the bowels kept free, and 
in simple cases medicinal treatment is not needed. If 
the fever is very high, one or two doses of antipyrin 
or acetanilid may be given, with the knowledge that 
cardiac depression readily occurs in this disease. Hot 
drinks, as hot lemonade or hot tea, with a little alcohol 
in some form for its physiologic action in dilating the 
peripheral blood-vessels and promoting perspiration, 
is a satisfactory method of reducing the temperature. 
Tepid sponging may be of benefit, and hot sponging 
should be given the patient daily if he is too ill for a 
hot bath. 

If a testicle is affected, the lesion is generally an 
orchitis, or it may be an epididymitis. Ice and cold 
applications are inadvisable in this metastasis from 
mumps. Warm, moist applications often relieve 
pain; but if the testicles are kept elevated and sur- 
rounded by absorbent cotton, and if perhaps some oil 
or fat, such as petrolatum, is applied, the inflammation 
will probably go away as rapidly as by any other treat- 
ment. Strapping is inadvisable in this complication. 
Any massage, or the rubbing in of any ointment or 
other preparation in this kind of orchitis, or to the 
parotid glands, is inadvisable in mumps. Ichthyol 
applications in from 10 to 20 per cent, strength, either 
in petrolatum or in olive oil, or glycerin and water, 
have been largely used locally in this inflammation. 
Lead and opium wash has been frequently used; but 
the less this inflamed gland is manipulated, the better. 

If the mammary gland becomes metastatically 
inflamed, the treatment is about the same as that for 
the parotid. If it is decided that the ovary is inflamed, 



112 MENINGITIS 

but little can be done, except absolute rest and the 
administration of a sedative if there is pain. If there 
is much pain from any of these inflamed glands, mor- 
phin or codein may be advisable if it seems unwise to 
give a coal-tar analgesic. 

MENINGITIS 

This disease occurs in epidemic and sporadic forms, 
the latter form being often difficult to diagnose. While 
young children and young adults are most often 
attacked, it occurs not infrequently in camps, or in 
other groups of closely associated individuals. The 
sporadic form is always more or less present in most- 
cities, and so-called "basillar meningitis" is doubtless 
generally this disease. Some epidemics in cities show 
a large number of very young children affected by it. 
Epidemics appear, both in this country and in Europe, 
most frequently in the winter and spring months, and 
the greatest number of sporadic as well as epidemic 
cases occur during March, April and May. 

The cause of epidemic cerebrospinal meningitis is 
the Diplococcus intracellularis meningitidis, also called 
meningococcus, which was first described by Weichsel- 
baum, in 1887. These cocci are found in the spinal 
fluid. In appearance they are very much like gono- 
cocci, and lie in pairs either in or near the leukocytes. 
These germs are also found in the secretions of the 
nose and nasopharynx. The meningococcus is of low 7 
vitality and is readily killed by sunshine, drying and by 
freezing; therefore, with ordinary precautions the 
danger of contagion is slight. As in so many other 
diseases, carriers of this germ have been found, and 
they probably play a considerable part in the spread 
of epidemics and in the occurrence of sporadic cases. 

From these facts meningococcus cerebrospinal men- 
ingitis should be made a reportable disease, whether 
occurring in sporadic or epidemic form, and carriers 
should be sought, and when discovered, isolated and 
treated. 

In the first place, it may be mentioned that rarely 
it has been noted that the disease has attacked an 
individual more than once. In the second place, 
carriers have become more or less immune, but it is 
self-evident that, having been discovered, although 



TREATMENT OF MENINGITIS 113 

close contact is needed, and though the germ is not 
sturdy and is readily killed after leaving the body, they 
must be isolated and treated. Therefore, the persons 
immediately surrounding a case of meningococcic men- 
ingitis should have the secretions of the nose and naso- 
pharynx examined for this germ. It has not been 
shown just what local treatment of the nose and throat 
of these individuals is advisable, but antiseptic sprays, 
swabbings and gargles are certainly indicated. 

Vaccinations, with dead meningococci, of children 
who have been directly exposed to the disease, and of 
the nurse or other persons, who must care for cerebro- 
spinal fever patients would seem to be advisable in 
preventing the spread of the disease. It has been 
suggested that a moderate amount of immunity would 
be sufficient to prevent this particular infection. How 
long immunity would last is not known. Vaccination 
with this germ causes a febrile reaction, with leukocy- 
tosis. Meningococcus vaccines are now prepared, and 
can be readily obtained. Sophian and Black have 
discussed this subject. Meningococcic vaccine has 
been injected, and antimeningococcic serum has been 
sprayed' into the noses and throats of carriers, with 
some success. It has not been shown how constantly 
this treatment is successful. 

TREATMENT 

Flexner has given us a specific treatment, and the 
method to be followed in its administration cannot be 
better described than by once more referring to 
Du Bois and Neal. 

If the fluid taken from the spinal canal is cloudy, 
they immediately inject antimeningitis serum, warmed 
to the body temperature, and injected slowly. They 
consider a syringe as dangerous, and adopt Koplik's 
gravity method. They state, in general, that the dose 
for an adult is from 20 to 40 c.c, and for infants and 
children from 3 to 20 c.c, the amount largely depend- 
ing on the quantity of fluid withdrawn, and the dose 
should usually be from 5 to 10 c.c. less than the amount 
of fluid withdrawn. They state that occasionally in 
true meningococcic meningitis they have obtained no 
fluid from the canal in spinal puncture, so-called dry 
tap. In such cases they have injected a small amount 



114 ANTIMENINGOCOCCIC SERUM 

of the antiserum, with careful watching of the patient 
to note changes in pressure as determined by the char- 
acter of the pulse and respiration. In severe cases 
they inject the antiserum every twelve hours until there 
is improvement. In moderate and mild cases they 
usually repeat the injection once a day for four days. 
The bacteriologic findings of the fluid withdrawn at 
the last injection, and the condition of the patient, 
determines whether the antiserum should be given 
longer. They state that usually from four to six 
injections are necessary, but they have given sixteen 
or more. On successive punctures and injections the 
patient is turned first on one side and then on the 
other, which they think insures the emptying of the 
lateral ventricles in rotation. In other words, a patient 
who lies on his right side for one puncture will be 
* placed on his left for the next. 

A number of times they have seen the patient go 
immediately into a condition of shock after the injec- 
tion of the serum, with the respiration shallow, the 
face pale, and the pulse rapid and thready. They 
have never, however, seen a patient die in this con- 
dition, and if the needle is still in place they withdraw 
some of the serum. Artificial respiration is resorted 
to if the breathing has ceased, and hypodermic stimu- 
lation of the heart is given. This condition of shock 
does not occur frequently with the smaller doses that 
are now administered. The serum they have lately 
used contains 0.2 per cent, of trikresol, and as they 
have used trikresol serum over five hundred times in 
patients of all ages, they do not believe that fatalities 
are due to the phenol contained. However, on account 
of objection having been made to trikresol, they are 
ready to try chloroform as a preservative. 

Barnes states that antimeningococcus serum differs 
from ordinary antiserums in that it is destructive to 
the meningococci, and at the same time neutralizes the 
endotoxins set free during the destruction of the 
germs. 

If a case of cerebrospinal fever shows a tendency to 
become chronic, Du Bois and Neal make an autogenous 
vaccine and give it every four or five days, "in doses 
of from 250 to 1,000 million" bacteria. They are not 



PAIN IN MENINGITIS 115 

convinced of the value of this treatment, but they have 
not seen it do any harm. 

The general treatment of cerebrospinal fever 
demands the best hygienic surroundings obtainable, 
and a quiet, cool, darkened room, as in any meningitis. 
The bowels should be thoroughly moved in the begin- 
ning, and then, daily, or every other day, the patient 
should receive a laxative, if needed. 

As the vomiting is reflex, stomach sedatives are of 
no avail. As the central condition is improved or the 
patient becomes more stupid, the vomiting will cease. 
Food in the early stages should not be pushed, as there 
is great repugnance to it. Plenty of water, and later 
simple cereal gruels and milk should be the early diet. 
The subsequent diet should depend on the height of 
the fever and the ability of the patient to digest. In 
the stage of convalescence food should be pushed, if it 
is well digested. Through the acute illness, starches 
should be given to prevent acidemia. If the pain is 
sufficient to require sedatives, much food should not 
be given, as it will not well digest. 

A most important symptom of this disease is likely 
to be pain, and there is no excuse for allowing a 
patient, because it is a young child, to suffer pain. 
Morphin or codein represent the most efficient and the 
safest drugs, the dose, of course, being regulated 
according to the age of the patient and the effect. 
Generally it is better to administer a very small dose 
hypodermically than a large dose by the mouth; the 
action of the whole dose is obtained, and there is no 
doubt as to whether or not it is absorbed. Ergot given 
in aseptic form, intramuscularly, not only seems to act 
as a sedative to the nervous system and possibly dimin- 
ishes congestion, but it certainly prolongs the action of 
any dose of a narcotic. Less morphin, codein or other 
narcotic will be required to stop pain and cause rest if 
ergot is coincidently given. If the blood pressure is 
low, this is another indication for the administration 
of ergot. Generally, if the blood pressure is high, 
ergot should not be given. 

Local applications of cold and ice to the head (the 
hair being cut short) and to the spine, may inhibit the 
inflammation, and sometimes seem to be of great value. 
At other times these cold applications seem to increase 



116 COMPLICATIONS IN MENINGITIS 

the pain. This seems tc^be especially true if the tem- 
perature is low. Exactly what these cold applications 
do to the blood vessels of the parts inflamed is a ques- 
tion that has not been determined. Cold sponging of 
the body is hardly advisable, as it tends to increase 
the internal congestion. Theoretically, it would seem 
more sensible, and practically it is often better to use 
hot applications, as hot sponging, and even hot baths 
have been advised, for very young children, to relieve 
the congestion of the central nervous system. 

Painful joints may be wrapped in cotton and kept 
warm, much as is done in rheumatism. Conjunctivitis 
should be treated with a simple boric acid wash. The 
throat and nose should be cleansed with simple saline 
sprays or mild antiseptic gargles. 

There would seem to be no excuse for the adminis- 
tration of quinin, strychnin, caffein, or any other cere- 
bral stimulant. It would also seem inadvisable to 
administer alcohol in any form. If the blood pressure 
is high, hot sponging, small doses of nitroglycerin and 
more brisk catharsis are indicated. 

The patient should remain in bed for at least a week 
after the cessation of the fever, and convalescence 
should be slow, and the return to activity should be 
delayed. During convalescence it is well to administer 
small doses of sodium iodid, as iodid seems to be effi- 
cient in aiding the absorption of exudates. Iron and 
other tonics may be indicated. 

Stiffening of the muscles and joints may require 
massage, and, if there are any adhesions in the joints, 
the orthopedist should be consulted as to whether pas- 
sive movements or forcible breaking up of these adhe- 
sions under an anesthetic is advisable. 

The frequency with which mental deterioration 
occurs can only be determined by a long careful study 
of many cases. Cerebral degenerations and disturb- 
ances may develop after many years and yet appar- 
ently have been caused by this disease. 

The various complications that may occur have 
already been mentioned, and their treatment would be 
that usual for the localized inflammation modified by 
tlu- general condition of the patient from the cerebro- 
spinal fever. 



ACUTE ANTERIOR POLIOMYELITIS 
It was not definitely shown, until 1909, that this 
disease belonged to the infections and was contagious, 
although it had been long suspected. 

PREVENTION 

It is quite probable that the so-called "distemper" 
which at times attacks dogs and may attack horses, is 
really caused by this same infection. Hence, a dog 
afifected with distemper should be isolated, and no 
child should be allowed to associate with it. While 
it has not been shown that flies will carry this disease, 
in all probability they may transmit the infection by 
their feet. Consequently, flies should be excluded by 
proper screens, if possible, from any animal that suf- 
fers from distemper, and certainly should be pre- 
vented from reaching an individual sick with polio- 
myelitis. 

As early as Feb. 12, 1910, Flexner and Lewis 
showed that this disease was contagious by means of 
the secretions of the mucous membrane of the nose 
especially, and also of the throat, and therefore that 
every patient should be isolated, and that the disease 
should be made reportable to the boards of health. 

The nurse and the family should understand that 
the same care must be exercised in destroying the 
contagium and preventing the contamination of arti- 
cles and substances by the secretions of the nose and 
throat of a poliomyelitis patient as is so well under- 
stood must be taken in diphtheria. 

As soon as a case is reported to the board of health, 
the school board should be informed (as such cases 
are frequently in children too young to go to school) 
that they may send home from school the other chil- 
dren of the family, and if there is an epidemic, per- 
haps the other children of that tenement. The incu- 
bation period is said to vary, and may be as long as 
ten days, but to be safe from causing infections in 
others, such children should remain out of school for 
two weeks. 

TREATMENT 

A. The Acute Stage. — The same care in isolation, 
and of the secretions of the nose and throat, to pre- 



118 ACUTE STAGE IN POLIOMYELITIS 

vent possible infection of others or contamination of 
articles, should be carried out as has been described 
for the other infectious diseases. Flies and all domes- 
tic animals must positively be excluded from the sick- 
room. As soon as the diagnosis is positive, the dis- 
ease should be reported to the board of health, 
whether or not it is a reportable disease in the 
community. 

As Flexner states that the virus is eliminated by the 
intestines as well as by the nose and throat, all move- 
ments of the bowels during the course of the disease, 
and perhaps for some little time after the acute stage 
is over, should be as thoroughly disinfected as they 
are in typhoid fever. It cannot yet be decided just 
how long quarantine should be continued, but two 
weeks should be the under limit, and better, three 
weeks. That more of the attendants or associates of 
a patient sick with poliomyelitis do not contract the 
disease may be because they are insusceptible, or they 
may have become immune from some previous abor- 
tive attack. 

When the disease has started, there is no known 
medical method of aborting it, although mild infec- 
tions may abort without paralysis. Netter makes 
intraspinal injections of the serum from persons who 
have had poliomyelitis at some time in the past 
assuming that the serum contains antibodies which 
will have a therapeutic action. In one case given ten 
injections of serum in eleven days, in a dosage of 
5-7 c.c, a beginning paralysis was halted. 

The treatment in this stage of the disease is to 
relieve cerebral and spinal congestion and remove all 
possible toxins that may be absorbed from the intes- 
tinal canal by free but gentle catharsis. Calomel, in 
one sufficient dose, associated with cascara, aloin or 
rhubarb, as deemed advisable, is always a good method 
of treatment. Castor oil is another, or at times a 
quickly acting saline cathartic may be advisable. Sub- 
sequently the bowels should be moved as frequently 
as the diet and the condition of the intestines seem to 
require. A child that is not taking much food for the 
first two or three days after the first cleaning out of 
the intestines need not necessarily be bothered with a 
laxative every clay during this first stage of the dis- 



PAIN IN POLIOMYELITIS 119 

ease. As soon as paralysis begins, it may be difficult 
to cause the bowels to move, and a simple glycerin 
suppository or a small enema may be needed. 

The child must not be allowed to forget to urinate, 
as some loss of normal bladder irritability may allow 
urine to be retained and distention of the bladder to 
occur. Therefore, the child should be encouraged to 
urinate at about four-hour intervals. Of course, if 
the urine cannot be passed, it must be drawn. 

Generally the fever is not high. If it is high, two or 
three small doses of acetanilid may be administered 
or sponging the body with warm water is advisable. 
General cold sponging or general cold applications are 
inadvisable, as tending to cause increased congestion 
of the central nervous system. The value of an ice 
cap as a reducer of temperature is doubtful, and it is 
likely to cause the child to become more restless. The 
value of a spinal ice bag is also doubtful, as many 
times these cold applications cause an increase of pain. 

Pain must be stopped in a child as well as in an 
adult; this fact is often forgotten. The physician 
allows a child to suffer because he dislikes to give 
strong narcotics, when an adult would demand some- 
thing to stop his pain. If there is high fever and a 
few doses of acetanilid have been given, this may pre- 
vent some of the pain, but pain is most safely com- 
bated by small doses of morphin, codein, or opium in 
some form. Perhaps there is no better method of 
giving this narcotic drug to a child than by means of 
the deodorized tincture of opium. The dose may be, 
even to a young child, one drop every hour until the 
child is sleeping or is quiet. If the child is very 
young, of course the dose should be less, and for a 
child 10 years of age the dose should be larger. If the 
brain is so affected that the child is stupid, pain is not 
much felt, and narcotics will not be needed. Unless 
the child is excessively nervous, restless, sleepless, and 
twitching and jerking about the bed, such cerebro- 
spinal depressants as chloral and bromid are not indi- 
cated, as one can but feel they might tend to increase 
the muscle debility and paralysis that must follow the 
acute stage of the disease. It seems safer and more 
rational to give for this condition opium or one of its 
alkaloids in a dose sufficient to cause quiet and rest. 



120 LOCAL TREATMENT IN POLIOMYELITIS 

In this disease, as in all forms of meningitis, the 
bedroom should be quiet and removed as far as possi- 
ble from all noise and disturbance. The child should 
not be unnecessarily spoken to, and there should be 
frequent darkening of the room in order that the 
patient may get all the rest possible. 

During the active stage food should not be pushed. 
Part of the diet should be milk, and the rest of it 
should be cereal gruels. The diet should not be 
wholly milk, for in this as in all acute diseases the 
possibility of acidemic conditions occurring should not 
be forgotten, and starches should always be given in 
the form most acceptable to the patient. The first 
day or two the child will be thirsty, and should be 
allowed all the water it desires. As soon as the fever 
diminishes or ceases, nutrition should be pushed, and 
the child should be encouraged to eat so that the gen- 
eral strength may be recovered as rapidly as possible. 
If at this time the tongue is coated, the digestion poor 
and the appetite insufficient, it may be because gastric 
acidity is insufficient, and a few drops (not more than 
five) of dilute hydrochloric acid, in water, after meals, 
may aid in overcoming these conditions. Or perhaps 
still better is the tincture of iron chlorid in a dose of 
not more than three or four drops, in a little fresh 
lemonade or orangeade. 

B. Local Treatment. — Fixation of the painful 
extremities and of the back, in the most restful posi- 
tion, with the aid of cushions and pillows, is important 
during the acute stage. As there is no special inflam- 
mation in any joint or muscle, cold or ice to a painful 
region is not indicated. Dry warmth may cause a 
lessening of the pain and is often of value. If the 
limbs affected become cold from disturbed circulation, 
they should be surrounded with cotton or covered 
with flannel. Restriction by bandages is inadvisable. 

During the first stages of the paralysis great care 
must be taken in watching the position of the limbs, 
especially the legs, to prevent contractions caused by 
the pulling of the unaffected muscles. Massage is 
soon valuable, but must be very gentle. Proper mas- 
sage will not only increase the nutrition of the affected 
muscles, but cause relaxation of spasm of the unaf- 



PARALYSIS IN POLIOMYELITIS 121 

fected muscles. It may be necessary to devise some 
apparatus to keep the leg or foot from becoming 
deformed. For this purpose various splints, or 
wooden or wire troughs properly padded with cotton 
may be used. Gibney and Wallace urge that the 
legs should be kept straight or in slight flexion at the 
knees and in line with the body, while the feet should 
be kept at right angles with the legs. 

The value of having the child, as early as possible, 
make slight voluntary efforts with the paralyzed mus- 
cles is excessively important. All neurologists and 
orthopedists now believe that one voluntary contrac- 
tion of a muscle is of very much greater value than 
many passive activities of a muscle or contractions 
caused by electricity or other irritant. 

Some writers believe that counterirritants applied 
to the spine, such as cautery treatments, are of value 
in hastening the stage of resolution of this disease. 
While they may be of value, consideration must 
always be given to the disturbance that it will cause 
the child who has suffered enough pain, and who 
already has difficulty in finding comfortable positions 
in bed. 

C. Paralysis. — When the circulation is poor in an 
extremity, the local application of heat in any form, 
and perhaps by baking, is of value. As soon as it is 
believed that all active inflammation in the spinal cord 
has ceased, electricity should be begun, and Jones 
believes that electricity should not be used until from 
three to eight weeks from the beginning of the infec- 
tion. Galvanism should then be used on the nerve 
trunks, gently and not too strong, while the muscles 
are caused to contract by faradism as long as they 
react to that current. If they do not react to the far- 
adic current, the galvanic current should be used to 
cause contraction by making and breaking. The rap- 
idity of the making and breaking galvanic current 
should not be too great, nor should any kind of mus- 
cle stimulation be continued too long at any one sit- 
ting ; in fact, at first only a few contractions should be 
caused. 

Voluntary training directed by a skilled orthopedist, 
and the application of any splints or apparatus that 



122 • HOOKWORM DISEASE 

may be necessary to prevent deformities and atrophies 
should soon be inaugurated, as Taylor and many 
others believe that massage and electricity are very 
ineffective in causing recovery of muscles paralyzed 
by poliomyelitis. All physicians and surgeons urge 
that the greatest improvement is caused by plenty of 
rest in bed, graded exercise, warm baths, good food 
and fresh air. In other words, the better the nutrition 
the greater the improvement in the paralyzed muscles. 
Muscles may even recover after a year or more of 
paralysis when treated by a skilled orthopedist. It 
should be emphasized that rough, harsh massage and 
misdirected use of electricity may do serious harm to 
the paralyzed and contracted muscles. In a word, the 
general practitioner should as quickly seek the aid of 
the orthopedist in treating the paralysis of this dis- 
ease as he would seek a skilled aurist in an internal or 
middle-ear inflammation. 

Surgical repair of deformities that cannot be cor- 
rected by apparatus or muscle training has now 
reached a stage never equaled before, and tendon 
transplantation and other orthopedic operative mea- 
sures cannot too soon be considered when improve- 
ment ceases to occur in a limb affected with paralysis 
from poliomyelitis. A recent discussion of this sub- 
ject is presented by Moore of Philadelphia. 

HOOKWORM DISEASE 

This disease is found in all tropical and southern 
temperate zones ; in the United States southward from 
the Potomac River latitude through to the Pacific 
coast. The symptoms are laziness, lassitude, weakness, 
loss of physical and mental ability and vitality, loss of 
weight and anemia. Children do not properly grow 
and adults become shiftless, incompetent, and poverty 
stricken, and they, with their families, become a tax 
on the community. Hence hookworm eradication is 
an economic question. 

The hookworm was discovered in Porto Rico by 
Major Ashford, Surgeon of the United States Army, 
but to Dr. C. W. Stiles of the United States Public 
Plealth Service belongs the honor of having found the 
worm in the southern states and of having shown 
that it differs generically from the Old World worm, 



THYMOL IN HOOKWORM DISEASE 123 

but that it causes the same symptoms. The American 
type of worm is called Necator americanus. 

The disease can be discovered by giving the specific 
treatment in a suspected case and then sifting or 
washing the stools through cheese cloth, when worms 
will be found, if present. 

The treatment is to give little or no supper, and 
at bedtime a dose of magnesium sulphate. In the 
morning, as soon as the bowels have moved freely, 
one-half the dose of thymol, in capsules, is given, and 
in two hours the remainder of the thymol. Two hours 
later another dose of magnesium sulphate is admin- 
istered. After movements of the bowels from this 
dose food may be taken, but only coffee or tea, with- 
out milk, should be allowed during the period of the 
treatment, namely, until the thymol has supposedly 
all passed out of the body. Absorption of thymol is 
not desired, as it may cause unpleasant symptoms. 
Alcohol and oils should not be given either before, 
during or even soon after the treatment. For one 
hour after taking the thymol the patient should lie 
on his right side to hasten the passage of the drug 
and liquid through the pylorus into the intestines. 

The dose of thymol depends on the age, but is large. 
Ferrell suggests 4 gm. (60 grains) for an adult dose 
(that is, from 20 years of age upward). Doses for 
children and youth may be readily estimated by the 
following formula, namely: At 15 years, % °f the 
age, J4 °f- the adult dose; at 10 years, y 2 the age, 
Yz the dose; at 5 years, % the age, % the dose; at 
2y 2 years, % of the age, y% of the dose. If the 
patient is much underweight for his age, the dose 
should be reduced accordingly. The thymol should 
be powdered and placed dry in capsules. One-half 
the dose decided on is given at 6 a. m. If the bowels 
have been well moved from the dose of magnesium 
sulphate the night before, the other half of the dose 
of thymol should be given at 8 a. m., both doses being 
taken with plenty of water. Ferrel adds sugar of 
milk in equal parts to the thymol, and says he thinks 
the drug acts better. 

In one or two weeks the treatment should be 
repeated, unless the microscope shows the feces to be 
free from the parasite and its eggs. Sometimes a 



124 THYMOL IN HOOKWORM DISEASE 

third and even a fourth treatment may be needed. 
The action of the thymol may be hastened by (at the 
moment of swallowing) uncapping the capsules. 

Thymol when absorbed acts like phenol, but it is 
slowly dissolved by the gastro-intestinal fluids and 
hence, is absorbed slowly. Any oil or fatty substance 
hastens its absorption. Convulsions are probably not 
often caused by thymol poisoning, but great weakness 
and finally collapse are the gross subjective symp- 
toms. Objective symptoms of its undesired absorption 
are albumin and even blood in the urine. Fatty 
degeneration of the liver and congestion of the kid- 
neys and lungs are pathologic findings. 

To forestall any possible great absorption of thymol 
after large doses are administered in hookworm dis- 
ease, a brisk cathartic (Epsom, Glauber's, or Rochelle 
salt) should be given and repeated, if free catharsis 
does not occur within a few hours after taking the 
thymol. Castor oil, or any other oil, should of course 
not be the cathartic used. If symptoms of poisoning 
occur, stomach-washing, colon-washing, and sodium 
sulphate or potassium and sodium tartrate should be 
the means used to promote elimination. Strong black 
coffee should be given, and hypodermic injections of 
atropin, strychnin, and pituitary extract should be 
administered and the patient should be surrounded by 
dry heat. Later, any kidney congestion should be 
treated as an acute nephritis. 

Except as a specific for hookworm, thymol should 
probably never be used internally. As a bowel anti- 
septic it is too dangerous a drug to be used repeatedly, 
unless the dose is too small to be of any value. 

Ferrell's dosage for adults for hookworm disease 
is as follows : 

Gm. 

R Thymolis 4| or gr. lx 

Fac capsulas siccas 10. 

Sig. : Take 5 capsules, with plenty of water, in the early 
morning, as soon as the bowels have moved. Take the 
other 5 capsules in two hours. Two hours later take Yi 
ounce of Epsom salt, which should be repeated if it does not 
act in four hours. 

( )wing to a possible scarcity of thymol it is impor- 
tant to note that investigations of the United States 



TYPHOID FEVER 125 

Public Health Service have shown that oil of cheno- 
podium (American wormseed oil) is efficient in this 
disease. (Public Health Reports, reprint No. 224, 
Oct. 2, 1914, by M. G. Motter.) 

Wormseed oil seems to paralyze or stupefy rather 
than kill the hookworm; therefore it is very essential 
that soon after such action has occurred, a cathartic 
should be administered to cause evacuation of the 
worms before they can recover their vitality. Unlike 
male fern and thymol, castor oil may be administered 
with this drug. It will be remembered that any oil is 
likely to cause a dangerous amount of male fern and 
thymol to be absorbed. This is not true of worm- 
seed oil. 

The doses of oil of chenopodium suggested in this 
pamphlet are about 1 drop for every year of age up to 
fifteen. The drug is well administered in a teaspoonful 
of granulated sugar, every two hours, for three doses. 
Two hours later, a child of ten years, for instance, 
should receive a tablespoonful of castor oil with one- 
half a teaspoonful of spirits of chloroform. The dose 
of the castor oil and of the chloroform should vary 
according to the age of the patient. 

Possible undesired symptoms from wormseed oil are 
drowsiness and depression. Such symptoms occurring, 
rapid purging should be caused by a saline cathartic, 
and such stimulants as hot coffee or caffein should be 
given, The pamphlet suggests hot coffee by the rec- 
tum, but while purging is going on, this would hardly 
seem worth while. 

The results with wormseed oil treatment in America 
have been corroborated in a large series of cases 
reported by Heiser from the Philippines. 

TYPHOID FEVER 

GENERAL PROPHYLAXIS OF TYPHOID FEVER 

Typhoid fever is one of the most preventable of 
all infectious diseases. The essential agent in the 
causation of typhoid fever, Bacillus typhosus, has been 
found in the blood, in the feces, in the urine, and in 
the bile. It cannot always be discovered in the early 
days of the disease, but in the second or third week 
it can generally be detected. It may persist for years, 



126 PROPHYLAXIS OF TYPHOID 

even as many as twenty-five or fifty, after a patient 
has become convalescent, and also in the body, par- 
ticularly in the feces and urine of individuals who 
have never themselves, so far as can be determined, 
suffered from an attack of the disease. These indi- 
viduals are known as "typhoid carriers/' 

After diagnosing the disease as typhoid, the physi- 
cian should at once report the case to the health office. 
Even should the case be suspicious only of typhoid, 
the following precautions may well be taken. The 
feces immediately on being passed should be covered 
v/ith a 5 per cent, solution of phenol, and the hard 
masses should be broken up so that the disinfectant 
will thoroughly penetrate the fecal matter and come 
in contact with all microorganisms which may exist 
therein. Other disinfectants may be used, such as 
chlorinated lime, or liquor cresolis compound, 2 per 
cent. The utmost cleanliness should be used by the 
attendants in connection with the movements of the 
bowels. The skin surrounding the anus should be 
carefully washed with a disinfectant solution, and the 
cloths used for this purpose should be put in paper 
bags and subsequently burned. The attendant also 
should, after bathing the patient, always wash her 
hands in a disinfectant solution. In a similar manner 
the urine should be discharged into a vessel and mixed 
with a disinfectant solution. 

The bacilli can sometimes be found in the sputum, 
and if the patient has any cough, the sputum should be 
collected on cloths and burned. 

All bedding should be soaked in a disinfectant solu- 
tion and boiled before being washed. The cups, 
glasses, dishes, knives, forks, spoons, and napkins used 
by the patient should also be disinfected before being 
washed. 

During convalescence, the feces and the urine 
should be subjected at intervals to bacteriologic exam- 
ination, to determine whether the bacilli are still pres- 
ent. It has been found that they may be absent at 
one time, and may reappear later, so that repeated 
examinations are necessary. The patient should be 
carefully isolated until repeated examinations have 
shown entire absence of bacilli, both from the feces 
and the urine. When these rules have been observed 



RULES FOR PREVENTING TYPHOID 127 

in the care of any patient suffering from typhoid, he, 
his friends, and the physician, will rest assured that 
there will be very little likelihood of his communi- 
cating the disease to anyone else directly or indirectly. 

As has been stated, the disease may be carried 
directly from the patient suffering from the disease, 
or from a so-called bacillus-carrier. The bacilli may 
be received directly by a person who does not possess 
immunity to the disease by handling articles, such as 
clothing or utensils used in eating, which have been 
contaminated by fecal matter, urine, or sputum from 
a typhoid patient. A far more common mode of infec- 
tion is the indirect method, w T hich embraces infection 
through water and through various food supplies, 
especially milk and oysters. Many epidemics have 
been due to the infection of a water-supply from 
patients suffering with typhoid. 

Jordan {Jour A. M. A., June 6, 1914, p. 1772) states 
the following rules, for the individual and the 
community in preventing typhoid : 

RULES FOR PREVENTING TYPHOID FEVER 

For the Individual: 

1. Keep away from all known or suspected cases 
of typhoid. 

2. Wash hands thoroughly before meals. Do not 
use "roller towels. " 

3. Use drinking-water only from sources known to 
be pure, or if this is not possible, use water that has 
been purified by municipal filtration or by hypochlorite 
treatment or by boiling in the household. 

4. Avoid bathing in polluted water. 

5. Used pasteurized or boiled, instead of raw, milk. 

6. Select and clean vegetables and berries, that are 
to be eaten raw, with the greatest care. 

7. Avoid eating "fat" raw oysters and, in general, 
oysters and other shell-fish whose origin is not known. 

8. Be vaccinated against typhoid in all cases in 
which any special exposure is known or feared. 

For the Community: 

1. Insist on the hearty cooperation of all persons 
with an efficient health officer. 

2. Require notification and a reasonable degree of 
isolation of every known or suspected typhoid case. 



128 VACCINATION AGAINST TYPHOID 

3. Exercise strict control over the disinfection of 
known typhoid excreta. 

4. Insist on pure or purified water-supplies. 

5. Require pasteurization of milk-supplies. 

6. Regard all human excreta as possibly danger- 
ous, and control their disposition in such a way as to 
prevent contamination of food or drink. 

VACCINATION AGAINST TYPHOID FEVER 

In 1893, Frankel first published his observations on 
the inoculation treatment of typhoid fever. In 1896, 
Wright published his first article on antityphoid inocu- 
lation. The British first introduced inoculation in the 
Indian army for the prevention of typhoid fever and 
demonstrated that the individual was protected by such 
inoculation for two and one-half years, and partially 
immunized for five years. In 1900, inoculation pre- 
vention was used by Germany, also, in her armies, and 
German and English military camps soon became 
almost free from typhoid fever by such protective 
vaccination. With the inauguration of this measure 
in the United States Army, typhoid fever became 
greatly diminished in frequency. Vaccination of our 
army was begun in 1909, and, in 1911, among 80,000 
men only 11 cases of typhoid fever occurred, with one 
death. In 1912 there were 15 cases in the army, with 
2 deaths. This shows that occasionally the typhoid 
inoculation does not protect, but the improvement 
shown by the diminution in the number of typhoid 
cases from 9.43 cases out of every thousand soldiers 
in 1901, to 0.26 for every thousand soldiers, in 1912, 
compels belief in its efficiency. The death-rate from 
this disease decreased, per thousand soldiers from 
0.64 in 1901 to 0.03 in 1912. 

The incubation period of typhoid fever is about two 
weeks. Its duration, when there are no relapses, is 
about two months. This means two weeks of incu- 
bation, four weeks of more or less serious illness, and 
two weeks before the real convalescence. Young 
adults and youth are most likely to contract this dis- 
ease, although it may occur at any age. This is the 
age, then, for the greatest effort to be made to give 
protective inoculations. All nurses and members of 



METHOD OF VACCINATION 129 

hospital staffs ; students of colleges and seminaries : 
employees, and those who are interned in work houses, 
jails, prisons and asylums; men in lumber camps; and 
all those who travel and are therefore subjected to 
varying water, milk and food-supplies, such as "travel- 
ing" men, engineers, seamen, tourists, and vacationists, 
should receive typhoid preventive vaccination. 

With all the advantages to an individual and to a 
community conferred by protection against typhoid 
fever by vaccination, the physician must also carefully 
consider what constitutes contra-indications. It seems 
to be wise carefully to examine every individual to 
ascertain his condition of health before vaccination is 
done. It should not be done if he is suffering from 
any acute infection however simple, namely, a coryza, 
a pharyngitis, a tonsillitis, or any acute gastrointes- 
tinal disturbance, gonorrhea, syphilis, albuminuria, 
glycosuria, or the more serious conditions of chronic 
nephritis or diabetes. The injections should be made 
in the afternoon, and the active symptoms will gen- 
erally be gone by noon of the next day. Three injec- 
tions should be given at weekly intervals. 

The method of injection is as follows: Paint with 
tincture of iodin an area about 15 mm. in diameter at 
the insertion of the deltoid muscle. Inject subcutane- 
ously with sterile needles and the best vaccine the dose 
of killed bacteria decided on. Then paint the region 
with collodion and allow it to dry. If proper care 
h taken, no infection will occur, and, as above stated, 
a temperature reaction is rarely above 100 F., and 
perhaps never reaches as much as 102 F., even in 
exceptional instances. A severe reaction could only 
occur when there is some serious complication in the 
individual, as perhaps tuberculosis. All slight reac- 
tions are generally over in twelve hours and even 
severe ones are generally over in twenty-four hours. 

The local reaction is greatest after the first dose, 
less after the second, and least after the third. 
Typically, there is an acutely inflamed area, varying 
in size, not hard and indurated like an incipient 
abscess. The arm may ache, and the axillary glands 
may become tender. The local reaction is generally 
at its height in about ten hours, and generally nearly 



130 TREATMENT OF TYPHOID 

gone in twenty-four hours. Any more severe reaction 
would be due to contamination. 

The dosage for children should be based on the 
child's weight and not on its age. The recommended 
adult dose is based on a weight of 150 pounds. It 
seems to be necessary for continued protection to 
revaccinate children more frequently than adults, 
namely, in about three years. 

TREATMENT OF TYPHOID FEVER 

A. General Measures. — Needless to state, the patient 
with typhoid fever should be put to bed and kept 
quiet. The usual measures such as the use of a 
cleansing cathartic should be instituted and simple 
fluid mixtures such as lemonade or citrate solution 
may be given. Patients should be encouraged to shift 
the position in bed sufficiently often to prevent the 
occurrence of congestion of any of the viscera or the 
appearance of bed-sores. The hygiene of the mouth 
should be watched, as mentioned for other diseases, 
w r ith scrupulous care. 

B. Diet. — Whether we have underfed our typhoid 
patients or overfed them, it seems that the evidence 
is very strong that milk alone is not the proper food 
for these patients. In fact, when we consider the 
frequent difficulty in its digestion, the large amount of 
it that must be given to satisfy the system either in 
calories or in protein, it would seem that we should 
rule against it as a typhoid diet. These facts imme- 
diately cause the decision that our old feeding of 
typhoid fever was wrong, and that we must select a 
new or modified food in this disease. 

It can not be questioned that the high temperature, 
rapid pulse, delirium, and that association of nervous 
symptoms called typhoid are not caused by the typhoid 
germ alone, but by a double infection, and the double 
or secondary infection is due to toxins or the products 
of secondary germs absorbed from the intestines. 

Tympanites is an indication not of typhoid fever, but 
of intestinal putrefaction and fermentation, and a 
mistake in the management of the bowels and of the 
food administered. 



DIET IN TYPHOID 131 

It stands to reason, then, that primarily such food 
and arrangement of the movements of the bowels as 
cause the least tympanites and the least indigestion 
are of first importance in the management of typhoid 
fever. Secondly, the food which, so far as possible, 
satisfies the requirements of the body for nutrition 
and at the same time satisfies the above requirements 
of easy and thorough digestion, should be the food 
of choice. 

Barker (Journal A. M. A., Sept. 12, 1914, p. 929) 
suggests the use of a high caloric diet which has been 
shown by Coleman, DuBois and others to be theo- 
retically adequate and practical. The amount of food 
necessary to meet the needs in typhoid fever is large. 
The carbohydrate intake is most important; when not 
contra-indicated for some special reason, it should 
make up, Coleman thinks, a half of the calories given. 
Fat seems to be better borne in the amphibolous period 
and during convalescence than in the earlier stages of 
the disease. 

Protein may be taken in sufficient amounts as eggs 
and milk. Schottmuller and other German writers 
give as much as 100 gm. of scraped meat per day, but 
in American clinics meat is rarely given, as it seems 
often to excite digestive disturbances and to increase 
renal irritation. Meat soups are also avoided, though 
a little broth or consomme may be given to improve 
the appetite and to stimulate the secretion of the gas- 
tric juice. If soup be given, it is well to add eggs and 
cereal to it to increase the caloric value. Eggs may be 
taken raw, or beaten up with milk, or as soft-boiled or 
coddled eggs. From four to eight eggs may often be 
given in twenty-four hours. 

The carbohydrate may be given partly as milk, 
partly as bread or toast (with butter), and partly as 
lactose added to the milk, cereals and orange-albumin. 
Coarse cereals with cellulose residue are to be avoided. 
Dry toast of zweibach buttered, if thoroughly chewed 
by the patient, may be used without harm. Boiled rice 
and mashed potatoes may be given as variety. Lactose 
is a very important article of the diet. It is easily sol- 
uble, is not very sweet, and can be given in large 
amounts without the appearance of sugar in the urine. 



132 DIET IN TYPHOID 

A liberal amount of fat in the diet will send the cal- 
ories up, but not all patients bear fat well, especially 
early in the disease. Fat may be tried in the form of 
cream, of butter and of yolk of egg. Coleman has 
been able to give as much as 200 or 250 gm. of fat 
per day without causing digestive disturbances. The 
fat content of ordinary milk is of course considerable, 
and milk in amounts of from 1.5 to 2 liters per day can 
be given to most patients without difficulty. Some 
patients, however, are intolerant of milk even when 
modified by pepton'zation, or by mixing with lime- 
water or with sodium citrate. Some patients take fer- 
mented milks very well, but the objection to them lies 
in the reduction of the carbohydrate content by the 
fermentation. 

Fruit juices, to which lactose has been added, may 
be given, as long as there is no diarrhea, but they 
should be discontinued should diarrhea develop. It 
must be remembered, however, that patients on the 
high-calory diet ordinarily have from two to four 
stools a day. 

It should be continually borne in mind that indi- 
vidual patients may not thrive under such a high- 
calory diet. Should tympanites or other digestive dis- 
turbances begin to appear, it is well to modify the diet 
at once and especially to restrict the intake of milk 
and of lactose. If, on the high-calory diet, examina- 
tion of the stools shows that undigested food is pass- 
ing through, the diet should be reduced. 

A good mixed diet for twenty-four hours, suitable 
for an ordinary adult ill with typhoid fever, is repre- 
sented by one pint of milk; two eggs, or the whites of 
three eggs ; one cup of thoroughly cooked, thin oat- 
meal gruel; the juice expressed from a pound of 
chopped round steak; a small cup of coffee, in the 
morning; a small portion of wine, orange, or lemon 
jelly made from gelatin; and enough salt and sugar 
in the above to make them palatable. 

The milk may be administered, hot or cold, with or 
without salt, with or without Vichy, with or without 
lime water, in two or three doses, as deemed best in 
the individual instance. Sometimes koumys makes a 
valuable substitute for ordinary milk. Sometimes but- 
termilk may be used, and this in larger quantities. 



COLON ENEMIES IN TYPHOID 133 

The eggs may be given raw, beat up with a little 
milk, or given with lemon juice on cracked ice, may be 
poached, or, if the temperature is not high, soft boiled 
or in the form of boiled custard. 

The oatmeal gruel should generally be made with 
milk, and thoroughly cooked, strained, and salted to 
suit the taste. 

Meat juice is best prepared by just covering the 
chopped steak with water, and allowing it to stand for 
an hour and a half. The water and juices are then 
expressed out of the meat. This watery extract will 
then contain, besides the blood of the meat, actual 
muscle serum, which is a decided tonic, especially to 
the heart. This expressed fluid is then kept on the ice 
and administered, properly salted, in two or three 
doses. If the patient is not too ill, the food may be 
made more agreeable by allowing the patient to chew 
the meat, but not swallow the fibrous portion. 

While gelatin is generally pleasant to most patients, 
it also has some nutritive value, and possibly tends to 
aid normal coagulation of the blood, and perhaps pre- 
vent capillary bleedings from the inflamed intestines. 

A patient who is accustomed to his morning coffee 
need not be deprived of that pleasure because he has 
typhoid fever, unless there are meningeal symptoms, 
or meningitis is actually present. 

Experience seems to teach that it is best to adminis- 
ter nutriment to the typhoid patient in small amounts 
at three-hour intervals. It should, however, be 
arranged that the patient has normal rest. In other 
words, he should not be awakened from a comforta- 
ble sleep because it is time to do something to him or 
for him, and at regular three-hour feeding intervals 
should be the periods at which he is to be disturbed for 
other treatments. During the night, if he is not seri- 
ously ill, he should not be disturbed as often as every 
three hours. 

With the treatment outlined, and with proper care 
of the mouth, the patient's tongue is rarely badly 
coated and should be moist, there should be no nausea, 
and there should be no tympanites. 

C. Colon Enemas. — It has been lately shown that 
fecal deposits, seeds or other food debris may become 
lodged in the lower corner of the ascending colon, the 



134 MEDICAL TREATMENT OF TYPHOID 

cecum, and may cause inflammation or symptoms of 
appendicitis, and may even be a subsequent cause of 
appendicitis. Hence it may be found to be good treat- 
ment, in the first few days of typhoid fever, to give 
colon enemas of from one to two quarts of warm 
water, the patient lying on his right side, to aid in 
washing away the possible accumulations in the cecal 
region. Such colon washings can certainly do no harm 
in the first days of typhoid, and may be of marked 
benefit in the future course of the disease. In other 
words, the more thoroughly the pathologic process in 
the intestines, in typhoid fever, is considered from a 
surgical standpoint, with the aim to keep these ulcers 
and the inflamed intestinal mucosa as clean as possible, 
the less will there be secondary infection, the less will 
there be tympanites, the less will there be deep ulcera- 
tions, hemorrhages and perforations, the less high the 
fever, and the better the whole prognosis. 

D. The Fever. — Hydrotherapeutic measures have 
become so universal in the treatment of the fever in 
typhoid patients that it is unnecessary to describe these 
measures in detail. The nerve stimulus due to the 
cold and the sedative effects of the bath are among 
the important effects it is desired to achieve. These 
results may be secured not only by actual tubbing 
but by sponging, packing, etc. 

Among the contra-indications to tubbing may be 
mentioned otitis media, hemorrhage, collapse, menin- 
gismus, etc. 

E. Medical Treatment. — Not only should the bowels 
be cleared at first, but subsequently the bowels should 
be moved daily. This is best done by administering 
every other day some gently acting saline laxative, 
which cleans the upper part of the intestines, tends to 
drain the portal circulation, to keep the liver, our 
Pasteur filter, in a healthy condition, and to cause an 
easy watery movement. Any tendency to a diarrheal 
condition or to too many movements from such a 
laxative may be stopped by the administration of 1/10 
grain of morphin. The bowels are thus cleaned and 
subsequent excessive peristalsis inhibited, and the 
patient is generally at rest for the remainder of the 
day. On the alternate day a small glycerin enema, 



DRUGS IN TYPHOID 135 

administered with a glass syringe, consisting of a 
tablespoonful of glycerin and a tablespoonful of 
water, will cause within ten minutes a movement 
of the bowels that will at least empty the descend- 
ing colon and cause the expulsion of gas. Such 
management of the bowels seems contra-indicated 
only by intestinal hemorrhage, signs of perfora- 
tion and great prostration. Such treatment also 
prevents secondary infections that keep the tempera- 
ture high. In other words, less antipyretic measures 
are needed, if the abdomen is flat, tympanites is not 
present, and the patient's bowels have moved daily 
artificially, and the movements are not caused by diar- 
rhea due to irritation from the disease. 

The best antiseptic to the upper part of the intestines 
seems to be salicylic acid in some form, and one of the 
best forms is the combination with phenol, viz., phenyl 
salicylate (salol), which may be given in capsules with- 
out any disturbance of the stomach, as it is there 
undissolved and breaks up into its component parts 
of salicylic acid and phenol in the duodenum. A small 
dose of this drug (0.25 gram or 4 grains) every six 
hours may be given continuously through the disease, 
unless there is a diminished excretion of urine, or 
albuminuria develops, or the urine shows darkening 
from the phenol, which would be very rare from this 
sized dose. Even the non-believers in bowel antisep- 
tics must admit that whether the colon bacilli or 
typhoid bacilli come to the upper part of the intestine 
by migration, or reach these regions through the blood 
stream, it would not be so healthy for them provided 
salicylic acid was present in the upper intestine as 
though it were not present. 

How good a bowel antiseptic hexamethylenamin 
(urotropin) is has not been determined, but in post- 
typhoid conditions when typhoid bacilli or colon bacilli 
may be present in the pelvis of the kidney or may be 
present in the gall-bladder, it has been shown that 
administration of hexamethylenamin is the best treat- 
ment to prevent their remaining permanently and caus- 
ing inflammation in these regions. 

Thus far sour milk treatments, lactic acid germs and 
the administration of yeast have not been mentioned. 
Certainly bowel infections of most kinds are made bet- 



136 VACCINES IN TYPHOID 

ter by the administration of yeast. The value of sour 
milk treatments in typhoid fever must be determined 
by experience. A patient, however, who is not doing 
well on the diet above suggested should be put on the 
sour milk treatment. One of the principle objections 
to such treatment is that the patient's stomach soon 
objects to any one diet that is to be long continued, 
although for a few days he might accept the soured 
milk. On the other hand, most patients do not object 
to the sour drink produced either by a tablespoonful of 
upper brewer's yeast in a glass of water, or by the 
solution of a five-eighths inch cube of a compressed 
yeast cake in a glass of water, given two or three 
times a day. 

F. Vaccine Therapy. — It is difficult to arrive at a 
just estimate of the value of vaccines in the treatment 
of typhoid fever, because the evidence for and against 
their use is derived from two widely different sources. 
From a theoretical standpoint, such a procedure has 
little justification. It is well known that there is an 
extensive invasion of the blood by the infecting organ- 
ism early in the course of the disease, and it seems 
reasonable to assume that, these invading organisms 
furnish sufficient antigenic stimulus to cause the maxi- 
mum antibody formation. On the other hand, if this 
antibody formation is delayed early in the course of 
the infection, vaccines may be of value in stimu- 
lating such a response. In the field of clinical medi- 
cine, many observers have reported striking results 
from the use of vaccines, and it is the common opinion 
of these clinicians that they are efficacious in the treat- 
ment of typhoid fever. 

The clinical data in the literature pertaining to this 
phase of the treatment of typhoid fever has recently 
been reviewed by Krumbhaar and Richardson of 
Philadelphia. This analysis includes more than 1,800 
cases, and in 95 per cent, of these, favorable results 
were observed. Thirty-five of the thirty-nine obser- 
vers concluded that the vaccine was useful as a thera- 
peutic measure. In almost all instances, the course of 
the infection was favorably influenced, and in many 
series the mortality was reduced. In a series treated 



SENSITIZED VACCINES IN TYPHOID 137 

by Petrowitch, the mortality was 3.2 per cent., as com- 
pared to 8 per cent, in 220 unvaccinated patients. 

Krumbhaar and Richardson (Am. Jour. Med. Sci., 
1915, cxlix, p. 406) used vaccines in the treatment of 
ninety-three typhoid patients in the Pennsylvania Hos- 
pital during the past three years. Their results were 
so promising that they consider the use of vaccines 
an important procedure in the routine treatment of the 
disease. The symptoms were rarely altered beyond a 
transitory rise in temperature; but relapses and com- 
plications were diminished in frequency, and when 
vaccine treatment was instituted early in the course, 
there seemed to be a favorable influence exerted on 
the intensity of the infection. Since agglutination is 
often absent during the first two weeks of the attack, 
these investigators assume that antibody formation is 
often delayed, and that by the use of vaccines an early 
activity of this process can be brought about. The 
experiments of Gay and Claypole also suggest that there 
may be a hyperleukocytosis following the injection of 
a vaccine during the course of typhoid fever. Should 
these experiments receive confirmation, a good theo- 
retical basis would be afforded for vaccine therapy 
in typhoid. 

The type and dosage of the vaccine have had no 
apparent influence on the results obtained. Sensitized 
vaccines have been strongly advocated by Besredka, 
Metchnikoff, Garbat and others, and on theoretical 
grounds such vaccines would be favored ; but the 
majority of investigators have had good results with 
suspensions of dead bacteria prepared according to 
Wright's method. Although autogenous vaccines gen- 
erally have been preferred, stock vaccines prepared 
from organisms selected for their high agglutinogenic 
power have been efficacious in the hands of many. 
Reports, however, have been so uniformly favorable 
with all preparations, that it seems as if the type used 
is of secondary importance. The dosage has also 
varied widely with different investigators. Semple, 
Waters, Petrowitch and others used small doses, while 
Foster, McArthur, Fletcher and Meakins obtained 
equally good results with large doses. Krumbhaar 
and Richardson gave 500 million as an initial dose and 



138 RESULTS WITH VACCINES IN TYPHOID 

two or three larger doses at short intervals. They 
conclude that their results were more favorable in the 
cases in which large doses were given. The dosage, 
however, must be gaged by the general condition of 
the patient. When the patient is very toxic, only small 
amounts of vaccine can be used with any degree of 
safety. 

Ichikawa obtained remarkable results from the intra- 
venous injection of sensitized vaccines. Using this 
method of inoculation, he was able to produce a rapid 
drop in the temperature to normal and often an early 
recovery. In his cases, mild intestinal hemorrhages 
occurred in a few instances following the injections; 
but these hemorrhages were no more numerous than 
in the unvaccinated patients. Subsequent investigators 
also report favorable results from the intravenous 
method of administration of the vaccine, but they 
strongly emphasize the danger of a severe general 
reaction in some instances. Signs of collapse, severe 
diarrhea and intestinal hemorrhages are complications 
which have occurred simultaneously with the rapid fall 
in temperature, and in a few instances there was an 
unfavorable termination. The ultimate value of this 
method of administration of vaccines, therefore, is a 
question which further observations must determine. 

The observations of Elmer (Jour. A. M. A., 1915, 
lxiv, p. 518) indicate that vaccines will not prevent the 
attack, once infection has begun. It seems probable 
that their use early in the course of the disease modifies 
the duration and intensity of the attack. Furthermore, 
in complications, especially localized typhoid infections 
such as periostitis and cholecystitis, and in the treat- 
ment of typhoid carriers, vaccines are of limited value. 
In local infections in which there is a secondary invad- 
ing organism, as in pneumonia and otitis media, 
typhoid vaccines are probably contraindicated. 

Careful bacteriologic and serlogic study is an essen- 
tial prerequisite to vaccine therapy, which requires 
an exact etiologic and early diagnosis. Before the 
question of the efficacy of this form of treatment can 
be settled fully, the mechanism of the action of vac- 
cines in generalized infections needs to be better under- 
stood ; obviously, this is a problem in the field of 



RHEUMATISM 139 

experimental medicine. In the meantime, the results 
at hand, which indicate that, used with discretion, 
vaccines not only do no harm, but also may be of 
benefit, should stimulate to further and careful obser- 
vations. 

G. Convalescence. — The patient should be kept in 
bed until the pulse regains its normal rapidity, and the 
amount of exercise that he is allowed to take should 
not be such as will increase the action of the heart 
beyond the normal rate. The patient should be allowed 
to sit up in bed. If this results in a marked increase 
in the heart rate, he should not be allowed to get up. 
It is also important that the nervous system should 
not be subjected to unusual irritation, and he should 
avoid cares and worries as far as possible. Protracted 
rest and a simple diet are essential features of this 
protective treatment. 

Before releasing the patient from observation the 
stools and urine should be examined repeatedly for 
the presence of typhoid bacilli. 

RHEUMATISM 

The average case of rheumatism presents usually 
a history of repeated attacks of acute or chronic tonsil- 
litis. "Sore throat" is also not uncommon in these 
cases. 

TREATMENT 

A case which is acutely ill should, of course, be 
managed like other cases of acute infection. 

The bowels should be carefully watched as to their 
condition. 

The use of salicylates in rheumatism should be gov- 
erned by observation of the effects of the quantities 
administered. Miller (Jour. A. M. A., Sept. 26, 1914), 
after a thorough investigation of the effects of the 
salicylates in rheumatism, concludes : "As salicylic 
acid after absorption circulates and appears in the 
tissues as a salicylate, it cannot act as a germicide 
unless the increased carbonic acid tension in the joint, 
the result of inflammation, reconverts it into salicylic 
acid. Statistics show that patients receiving salicylate 
are free from pain much earlier than those not treated. 
As the treated patients much more frequently relapse 



140 PAIN IN RHEUMATISM 

than the untreated, however, the total duration of pain 
in the treated and untreated patients may not be 
materially different. The period of stay in the hospi- 
tal of patients receiving salicylate and of those receiv- 
ing other forms of treatment is the same. Cardiac 
complications are not less frequent since the use of 
salicylates. In rabbits the prophylactic use of salicyl- 
ate is of no value in preventing arthritis after intra- 
venous injections of hemolytic streptococci. " 

Wood (Abstr. Jour. A. M. A., June 13, 1914, p. 62) 
advises the use of acetates and citrates which are 
oxidized in the body into carbonates and therefore 
act as systemic antacids. The potassium salts, he 
believes, are slightly more active as diuretics than the 
corresponding salts of sodium and increase the com- 
pleteness of the oxidative process in the body, thereby 
lessening the amount of uric acid to be excreted. 
From 20 to 30 grains of the salt should be given every 
two or three hours, or until the urine becomes alkaline. 

PAIN 

For the relief of pain a small amount of morphin is 
better than a large amount of a coal-tar product. This 
is always true when pain is constantly recurring. The 
repeated administration of any coal-tar preparation is 
inadvisable in acute conditions. 

The most important measure is immobilization and 
protection of the inflamed joint. Measures should be 
employed which increase hyperemia, such as wrapping 
in cotton batting, hot applications and counter irri- 
tation. 

The care of the individual joints which are inflamed 
cannot be dogmatically dictated. The joint and limb 
should be placed in the position that gives the patient 
the most comfort. If several joints of a limb are 
involved, and especially if there tends to be more or 
less troublesome muscle contractions, or an inadvertent 
movement causes excruciating pain, a splint may be 
devised to keep the limb at rest. Whether cold appli- 
cations or warm applications are the best for other 
joints, depends on the feelings of the patient. Too 
continuous cold is perhaps best not applied, as tending 
so to deteriorate the circulation of the part as possibly 
to do harm. Generally, warm, moist applications, and 



CONVALESCENCE IN RHEUMATISM 141 

perhaps nothing better than alcohol fomentations (one 
part of alcohol to 3 or 4 parts of warm water; a towel 
or napkin soaked in this and then wrung out just suffi- 
ciently not to drip, and this wound around the joint 
and then covered with oil silk) will probably give as 
much comfort as any application. These should be 
changed as frequently as they are cold. Sometimes 
dry cotton around the joint causes as much comfort 
as any application. The official methyl salicylate may 
be applied, or oil of wintergreen, but probably neither 
k more valuable than the above alcohol dressing. 

Later w T hen the acute inflammation in the joint has 
subsided, but the inflammation tends to persist in cer- 
tain joints, ichthyol applications are much used and 
seem at times to be efficient in hastening the absorption 
of exudates. Ichthyol may be used in from 10 to 25 
per cent, mixture with glycerin, or with olive or other 
bland oil. When there is acute rheumatic inflamma- 
tion in the joint, counter-irritation is contra-indicated, 
but when a subacute inflammation persists, either fly 
blisters or the actual cautery may be advisable. 

Anemia which so often follows rheumatism is per- 
haps frequently due to abstinence from meat and the 
prolonged administration of salicylates and alkalies. 
The constant administration of iron throughout the 
disease and a not too long use of salicylates and alka- 
lies will generally prevent this condition. 

The convalescence following rheumatism should be 
prolonged until the patient is thoroughly able to attend 
to his work. If there is a cardiac complication, such a 
recommendation is positively necessary. It can never 
be determined how much endocardial inflammation 
was present, how much valvular inflammation and 
thickening will be permanent, or how perfect the 
repair of the heart may be. Also, even when auscul- 
tatory evidence of cardiac complication has not been 
discovered, there may have been some inflammation 
which should call for prolonged rest. The adminis- 
tration of small doses of an iodid, best sodium iodid, 
from 0.10 to 0.20 gram (from l J / 2 to 3 grains) three 
times a day, is often advisable. Such treatment has 
frequently seemed to hasten or aid in the complete 
recovery of endocarditis. Not every endocarditis from 
rheumatism leaves valvular lesions. 



142 CHRONIC ARTHRITIS 

Meat does not cause rheumatism, and prolonged 
abstinence from meat is generally inadvisable, still 
but a small amount of purin foods should be taken 
for some time. Eggs, green vegetables, and cereals 
should constitute the main food; later, fish or meat 
once a day may be allowed. 

VACCINE TREATMENT 

Greeley (Abstr. Jour. A.M. A., July 4, 1914, p. 62) 
treated patients suffering from rheumatism with vac- 
cines made from streptococci isolated from the joints, 
the pharynx, the blood or the urine. He found uni- 
versal improvement after the use of such autogenous 
vaccines. No case should be given a vaccine during 
an exacerbation, marked by acute joint swelling, pain 
or fever. 

COMPLICATIONS 

Circulatory weakness during rheumatic fever may 
be combated with strychnin, with camphor, with aro- 
matic spirits of ammonia, rarely with alcohol, some- 
times with caffein, and exceptionally with strophan- 
thus or digitalis, the latter provided that there has not 
been prolonged high fever and there is no acute endo- 
carditis present. 

In the treatment of this disease, it should be urged 
that the heart be watched daily by stethoscopic exam- 
ination, to note as soon as signs of endocarditis occur. 
This complication is so insidious that it may not cause 
symptoms appreciable to the patient. There may, how- 
ever, be an increase of temperature, as there may be 
cardiac pain or distress. While it is not the object of 
this article to describe the treatment of endocarditis, it- 
may be stated that an ice bag over the heart may 
inhibit the inflammation, that the salicylates should be 
stopped if endocarditis occurs, and that rest and con- 
valescence after such a complication should be greatly 
prolonged. 

CHRONIC ARTHRITIS 

Chronic arthritis develops not only as a result of 
long continued bacterial infection but also on a basis 
of metabolic disturbances, gastro-intestinal derange- 
ment, etc. The blood carries to the joints "chemical 
products of bacterial growth, products derived from 



TREATMENT OF CHRONIC ARTHRITIS 143 

the gastro-intestinal tract, metabolic products of organ 
activities, and drugs, such as lead." Bacteria may 
locally infect a joint and produce substances that are 
irritant. Mechanical injury to the joints whether irri- 
tation, pressure, overwork, or insufficient circulation 
from some old injury or anything that disturbs the 
nutrition of a particular joint or set of joints may 
become causes of chronic arthritis. The following 
localities deserve attention as being the possible 
sources of toxins in such cases : the teeth, tonsils, naso- 
pharynx, bronchial tubes, bronchiectatic cavities, infec- 
tions of the gall bladder, appendix, seminal vesicles or 
Fallopian tubes. 

TREATMENT 

"The main problem," says Billings (abstr. Jour. 
A. M. A., Oct. 10, 1914, p. 1325), "is to get rid of the 
systemic infection." Primary rest is necessary as 
long as motion causes pain. The etiologic factor must 
be sought and removed if possible. The metabolism 
of the patient should be studied thoroughly, and the 
analysis should include repeated examinations of the 
excretions. Worry, nervous frets and mental irrita- 
tion should be avoided. 

In the treatment of individual joints, the measures 
mentioned under rheumatism should be borne in mind. 
Hyperemia about the joint may be produced and body 
baking may be of value in more generalized affections. 
In varying time, from four to six weeks, according to 
Billings, passive motion with gentle massage may be 
begun. The amount of passive exercise must be 
gauged by the effect on the individual. The patient, 
always more or less nervous, tires easily. To these 
patients tire is painful. Day by day the exercise must 
be increased. The rest, restorative measures (food, 
etc.), should improve the general nutrition and 
blood circulation. The passive exercise will gradually 
improve the local blood circulation and oxygen supply 
to the infected tissues. In due time active exercise 
is added. This must be systematically and regularly 
performed. Usually a nurse or masseuse should teach 
the patient the lighter forms of calisthenics. These 
measures, namely : rest, restorative food, pure air, 
environment of optimism, graduated passive and later 



144 VACCINES IN CHRONIC ARTHRITIS 

active exercises will overcome the debility, malnutri- 
tion and poor general circulation. They will also help 
to restore the local circulation and oxygen supply to 
the infected tissues. By these measures the natural 
defenses of the body are improved, the infected tissues 
become richer in oxygen and consequently a poor cul- 
ture medium for the invading micro-organism. Finally 
the destructive progressive metabolic changes of the 
tissues cease. Gradually one may note favorable 
changes in the joints. Atrophied, contracted muscles 
increase in bulk and functionate. But one dare not 
relax the control of the patient. Daily systematic 
passive and active exercises increased gradually must 
be continued until a relative restoration occurs. Other- 
wise a relapse is apt to occur because of neglect of one 
or more of the above important factors relating to 
nutrition, general and local blood supply, etc. 

Autogenous vaccines made up of the dominating 
strains of streptococci obtained from the tissues and 
exudates of the focus of infection have been used by 
Billings. The dose used has been from 100,000,000 to 
1,000,000,000. The large dose does not seem to be 
any more effective than the small one. The use of 
autogenous vaccines appears to increase the defenses 
of the body as judged by a study of the opsonins and 
phagocytic index. It is Billings' opinion that the gen- 
eral measures of management and treatment are abso- 
lutely necessary to succeed in helping these patients. 
To this management may be added autogenous vac- 
cination without fear of harmful results. The use of 
vaccines in the treatment of chronic deforming arthri- 
tis without attempting to find or remove the domi- 
nating etiologic focus of infection and without a sys- 
tematic hygienic management is irrational and most 
unjust to the patient. 

Medicinal treatment, except such treatment as is 
aimed to promote digestion, proper bowel activity, 
proper circulation, and proper character of the blood, 
is of little value. If there is thought to be hyper- 
acidity of the secretions or at least decreased alka- 
linity, alkalies may be of value, but certainly alkalies 
should not be pushed to the point of interfering with 
stomach digestion. Salicylates are of but little value 



ARTHRITIS DEFO .MANS 145 

in chronic joint disturbances. Iodids in large doses 
will produce waste, and may be what a fat patient 
needs. Small doses of iodid stimulate the thyroid to 
extra activity, promote general metabolism, and may 
be of value in the individual case. Colchicum in 
chronic arthritis is probably of little value except as 
it may increase intestinal activity. All of the various 
lithia salts, and all of the various laxative and alkaline 
waters have no specific action, but if combined with 
increased muscular activity increased activity of the 
skin, increased drinking of water in proper selected 
cases, a regulated diet and a regulated life, in other 
words, proper regime, they may be of apparent benefit. 
It is the regime, however, and not the particular kind 
of lithium or other salt that works the cure. 

ARTHRITIS DEFORMANS 

The etiology of this disease is only now being 
worked out. The relation of infection elsewhere in 
the body, to this disease has been emphasized, espe- 
cially by Billings and cannot easily be overestimated. 
The changes in the joints are not due to the absorption 
of toxins from the focus alone, but to actual localization 
of the bacteria themselves. The difficulty in obtaining 
the causative organism is great, owing to chronicity; 
but by improved methods Rosenow has succeeded in 
isolating peculiar streptococci from the excised lymph- 
glands draining the involved joints, from contracted 
and diseased muscles, and from excised portions of 
the diseased capsule of the joint itself, and recom- 
mends the use of the vaccine prepared from organ- 
isms thus isolated rather than from the streptococci 
in the focus. The use of even these vaccines, how- 
ever, is quite futile unless the focus is removed. The 
peculiar character of the changes, in which there is a 
proliferation of endothelial cells in the blood-vessels 
about the involved joints with a consequent anemic 
necrosis, makes it clear that no matter what vaccine 
or other remedial agent is used, cure in advanced cases 
will be exceedingly difficult. Removal of the focus, 
the judicious use of autogenous vaccines in small 
doses prepared not from the focus but from the adja- 
cent lymph-gland or tissue itself, together with rest, 
good air, passive motion and forced feeding comprise 



146 TETANUS 

at present the rational procedures and are yielding 
substantial results. The streptococci isolated are quite 
different from those obtained in rheumatism ; hence 
the uselessness of employing rheumatism vaccines. 

TETANUS 

The occurrence of thousands of cases of tetanus in 
the soldiers engaged in the war between the dual and 
triple alliances and the numerous cases in our own 
country following Fourth of July injuries, makes the 
prevention of tetanus an important subject. The 
anaerobic organism responsible for this disease is, it 
has been said, widely prevalent in the soil of France 
and Belgium, where most of the war was carried on, 
due to the intensive cultivation of the soil in these 
countries. 

THE PREVENTION OF TETANUS 

For convenience the important points in the prophy- 
laxis may be summarized as follows : 

1. Carefully and thoroughly remove every particle of for- 
eign matter from the wound, laying it open, if necessary, 
under anesthesia. 

2. Dry the wound thoroughly, and paint it and the sur- 
rounding parts as carefully as possible with iodin, or else 
cauterize it thoroughly with a 25 per cent, solution of phenol 
(carbolic acid) in glycerin or alcohol. 

3. Apply a loose wet pack, using a solution of some such 
antiseptic substance as boric acid or alcohol. 

4. As soon as possible inject intravenously or subcutaneously 
1,500 units of antitetanic serum and continue the injections 
if indications of possible tetanus arise. 

5. In no case close the wound. Allow it to heal by granu- 
lation. Remove the dressings and packing each day and 
apply fresh ones. 

Ritter, on the basis of observation of 60,000 
wounded in Bavaria, believes that our ordinary meas- 
ures are not sufficiently severe ; 0.7 per cent, of the 
wounded died and 0.4 per cent of the deaths were 
caused by tetanus. Even prophylactic injections of 
serum were not always able to ward off the disease. 
Freidrich makes a practice of excising the wound all 
around for 1 cm. into sound tissue, both at the surface 
and in the depths. This method is the ideal, Ritter 



TREATMENT OF TETANUS 147 

declares, but it is not always applicable. Another 
method is to apply hyperemia according to Bier's stasis 
technic. This washes out the wound from within on 
account of the higher blood pressure in the tied-off 
limb. He urges a trial of this measure on a large scale. 
Copious application of Peruvian balsam or its equiva- 
lent checks the production of hard crusts behind which 
the secretions can accumulate. Painting with tincture 
of iodin is a step in the right direction, he reiterates, 
but it does not go far enough. 

THE TREATMENT OF TETANUS 

The use of full doses of antitetanus serum given 
as soon as the earliest symptoms appear is the measure 
of greatest importance in the treatment of this dis- 
ease. Irons (abstr. Jour. A. M. A., Oct. 14, 1914, p. 
1505) analyzed the results of 225 cases of tetanus 
treated with various measures. 

Irons believes that the delay of treatment until the 
second or third day of symptoms, and the small doses 
(1,500 to 3,000 units) which a number of these patients 
received, go far toward explaining the failure of these 
methods to reduce the death-rate in this series below 
50 per cent. The unfortunate fact that often patients 
do not apply for treatment until the second or even 
the third day of symptoms can not be used as an 
argument against a method of treatment which offers 
a reasonable hope of success if instituted early in the 
disease. Magnesium sulphate was given intraspinally 
in eighteen cases which also received serum. Four 
cases, two acute and two chronic, recovered giving a 
mortality for the group of 77 per cent. In two cases 
death occurred shortly after the injection, with symp- 
toms of respiratory paralysis. 

Irons emphasizes that it is important that the full 
effect of the antitoxin should be obtained immediately 
and this may be accomplished by giving 3,000 to 5,000 
units intraspinally and 10,000 to 20,000 units intra- 
venously at the earliest possible moment after symp- 
toms of tetanus appear. On the following day the 
intraspinal injection may be repeated. The blood 
remains strongly antitoxic for several days. On the 
fourth or fifth day 10,000 units should be given sub- 



148 ANTITOXIN IN TETANUS 

cutaneously to maintain the antitoxin content of the 
blood. If only a small amount of antitoxin (3,000 to 
5,000 units) is available it should be given intra- 
spinally. Intraspinal and intravenous injections should 
be given with all the precautions usually employed 
for these methods. 

This use of antitoxin in no respect replaces other 
necessary recognized non-specific methods of treat- 
ment in tetanus. Surgical treatment of the site of 
infection should be instituted at once. The patient 
should be placed at rest in bed in a quiet, darkened 
room, and should receive sufficient sedatives to con- 
trol convulsions, together with adequate supply of 
fluid nourishment, and attention to the elimination by 
kidney and bowel. The necessity for large and con- 
tinued doses of sedatives such as chloral or chlorbu- 
tanol should not blind the physician to the possible 
danger of giving an overdose. The condition of the 
patient should be carefully watched, and a revision of 
the standing orders for sedatives made whenever 
symptoms suggest the decrease or increase of dose. 

When tetanus is once installed, according to Wein- 
traud, who observed numerous cases among the Ger- 
man wounded, little can be hoped from serum treat- 
ment but we have an important symptomatic aid in 
the Meltzer and Auer's magnesium sulphate treatment. 
The dosage when given subcutaneously should be 

15 or 20 c.c. of a 20 per cent, solution or 12 or 16 c.c. 
of a 25 per cent, solution. 

Permin (abstr. Jour. A. M. A., Jan. 10, 1915, p. 
170) examined the reports of 388 cases in Denmark. 
He suggests the following method in severe cases : 
Proceed the moment the tetanus is diagnosed to draw 

16 or 33 c.c. of cerebrospinal fluid by lumbar puncture 
and inject 1,000 or 2,000 antitoxin units. With 
extreme opisthotonos slight general anesthesia may be 
required. The foot of the bed should be raised to 
send the serum up the spinal canal. If lumbar punc- 
ture is impracticable, he makes an intramuscular injec- 
tion of the same amount. Then the wound is exam- 
ined and foreign particles removed, the opening 
enlarged, and the cavity rinsed with some antiseptic 
and tamponed with silver nitrate gauze, providing for 
ample drainage. The intraspinal or intramuscular 



TETANUS IN EUROPEAN WAR 149 

injection is repeated each day for five or six days and 
then every third day until marked improvement is 
observed. 

The serotherapy by no means does away with the 
necessity for chloral or morphin. The dosage must 
be proportional to the age of the patient and the 
severity of the tetanus. Some clinicians give very 
large doses of chloral, but Permin thinks it is wiser 
to keep below the maximum dose and supplement the 
chloral with morphin, keeping the patient in a quiet, 
darkened room. It is of the utmost importance that 
the patient should get adequate nourishment as the 
resisting powers depend to such an extent on this. 
Fluid foods are best and with extreme lockjaw it may 
be necessary to pull a couple of teeth to permit the 
introduction of a rubber tube through which fluid 
nourishment can be poured into the mouth. 

Daumsler, chief physician of the French army, 
administers 6 gm. of chloral every six hours until the 
patient is in a state of torpor and all hyperexcitability 
is abolished. 

Sainton says that six patients of twenty-two with 
tetanus recovered. In two of these the tetanus was of 
the severest type. His treatment consisted of a sub- 
cutaneous injection twice a day of 40 or 50 c.c. of a 
2 per cent, solution of phenol — the Baccelli method. 
The patients were isolated in semi-darkness, and twice 
a day each was given an enema consisting of 6 or 8 gm. 
of chloral, one or two yolks of eggs and 250 gm. of 
milk. The phenol injections were kept up more than 
a month in two cases, one receiving a total of 48 
and another 88 gm. of phenol. The doses of phenol 
given by Sainton do not approximate the fatal dose, 
which is in most cases as much as 15 gm. (y 2 ounce). 
It should be remembered that tetanus is an extremely 
fatal disease, and all forms of treatment employ heroic 
doses of the remedies used. The doses given by 
Sainton are about 50 per cent., above those recom- 
mended by Baccelli. Baccelli thinks that patients with 
tetanus are extremely tolerant to phenol. 

The dose of chloral is considerably above doses 
which have proved fatal in exceptional cases, but the 
chloral in tetanus is probably largely counteracted by 



150 CHOLERA 

the convulsive condition of the patient. While the 
minimum fatal dose of chloral has been put at from 
1.5 to 2 gm. (20 to 30 grains), much larger doses have 
been used in tetanus without serious results. In a 
case of tetanus, 93 gm. or 3 ounces were given in 
twenty-four hours without causing death. This is of 
course, exceptional. Anders recommends chloral to 
be given by rectal injections, 2.59 gm. or 40 grains, 
at a dose. 

Other methods of treatment include the injection 
of hydrogen peroxid directly into the wound, expos- 
ing the wound to a continuous stream of oxygen, and 
the blowing into wounds of a powder composed of one 
part chlorinated lime and nine parts bolus alba (Kao- 
lin), and the use of a dressing of powdered antitoxin. 

CHOLERA 

Cholera, which is infrequent in the United States, 
has been more widely spread recently in Europe, due 
to the traveling of large bodies of troops. It is re- 
grettable that serum prophylaxis in this disease is not 
so efficient as in typhoid. Rosenthal (abstr., Jour. 
A. M. A., Oct. 10, 1914, p. 1330) gives the following 
outline of the prophylaxis: Each person can effectu- 
ally protect himself against cholera by extreme clean- 
liness and avoiding unboiled water and uncooked 
foods. The most important general prophylactic mea- 
sure is the isolation of the sick. The disease starts 
almost always with diarrhea, and although the patient 
may still feel quite well yet he is already scattering 
germs in his diarrheic stools. A soldier with profuse 
diarrhea should go at once to the hospital and stay 
there. Even before it is possible for bacteriologic 
examination of the stools, the leukocyte count and 
blood-picture may reveal the presence of cholera in- 
fection and permit the discharge of the men with 
ordinary harmless diarrhea. 

Even direct exposure to cholera does not necessarily 
entail the disease unless the system is depressed from 
any cause, and he urges for this reason restriction of 
the sale and use of liquor, avoidance of physical ex- 
cesses, raw fruit, etc. Before eating and especially 
before preparing food the hands should be thoroughly 



PREVENTION OF CHOLERA 151 

cleansed with soap and water. The face and particu- 
larly the mouth should not be touched by the hands. 
All fluids should be boiled before drinking, except 
beer, wine and natural mineral waters. If water has 
to be taken raw, the danger of infection can be ma- 
terially reduced, he says, by adding a little acid, a 
knife-tip of citric acid to half a liter, or 20 drops of 
liquid phosphoric acid. The army corps should have 
a supply of each. He insists that it is unnecessary to 
use a disinfectant for the hands, and that spraying 
the rooms and clothes with a solution of phenol does 
no good whatever and merely serves to lull into false 
security. Disinfectants are of no use for the desired 
purpose except in the privies, and even here milk of 
lime is preferable to phenol. The linen and the dejecta 
from the sick require of course thorough steriliza- 
tion. There is no transmission of cholera, typhus or 
dysentery through the air. In Bulgaria he used to see 
persons extremely punctilious in singeing their dishes 
with alcohol and toasting all their bread, and yet they 
would. eat raw fruit and drink unboiled water. 

The measures tending toward alleviation of dis- 
agreeable symptoms should be adopted. Diarrhea 
should be checked, castor oil may be given to govern 
bowel's movements and bismuth subnitrate to cover 
denuded portions of the intestine. Morphin is useful 
in alleviating cramp. 

Brachio, in a recent severe epidemic in Europe, 
(abstr. Jour. A. M. A., Oct. 3, 1914, p. 1236) found 
iodin extremely effective, the best method being an 
intraperitoneal injection of a mixture consisting of 
iodin, J4 g ra i n > potassium iodid J4 grain, distilled 
water, 20 M. In almost all cases the treatment was 
supplemented with a free use of epinephrin, dropping 
the solution on the tongue. Naame has shown a strik- 
ing analogy between the cholera syndrome and the 
symptoms from defective functioning of the supraren- 
als. He injects epinephrin subcutaneously in doses of 
4 to 6 mg. in twenty- four hours, over several days, 
supplemented by saline infusion. 



PNEUMONIA 

Pneumonia is a general infection with a primary 
local manifestation in the lungs. There is no specific 
treatment, but the proper management of all details 
in the care of the patient causes a splendid percentage 
of recovery from this disease, which tends to recovery 
less than most acute infections. 

Bronchial pneumonia is a disease of early childhood, 
of old age, and sometimes secondary to other infec- 
tions, and to anesthesia ; while lobar pneumonia may 
occur at any time of life. The duration of bronchial 
pneumonia is indefinite. Lobar pneumonia typically 
is self-limited, and from this standpoint tends to re- 
covery, but complete recovery in any given length of 
time depends on the management of the patient. 

The prevention of pneumonia in any individual is 
dependent on the establishment of resistance by ob- 
servation of hygienic measures, the avoidance of undue 
exposure and the avoidance of alcoholic intoxication 
or other depression. 

TREATMENT 

Pneumonia of the sthenic type, which manifests 
itself by symptoms pointing to a forcible circulation 
is best treated in the open air. The high temperature 
which accompanies this condition may be controlled 
by methods not connected with drugging. The patient 
should be placed in the open air. The preparation of 
the patient for open air treatment in winter should be 
as follows : A blanket is spread over the woven wire 
spring large enough to extend beyond the sides and 
below the foot. Over this is spread a rubber sheet 
or paper and then the mattress. Next the blanket and 
rubber sheet are folded up over the mattress and se- 
cured with safety pins. The patient is clothed in a 
light suit of flannel, stockings and a hood. He is 
covered with enough to keep him warm. The lighter 
weight warm clothing, such as eiderdown quilts, if 
possible, are preferable. A hot-water bag at the feet 
completes the equipment. Hyperpyrexia, or prolonged 
temperature of 104 F., can be well combated by rolling 
the bed of the patient into a warm room or closing 
the windows and warming up the room in which he 



TREATMENT OF PNEUMONIA 153 

is ill, and sponging him with tepid, cool or cold water, 
depending on the height of the fever. 

For cleanliness the patient, unless critically ill, 
should be sponged daily with hot water or with tepid 
water. Meara emphasizes the necessity for careful 
cleansing of the mouth, nostrils and eyes of pneumonia 
patients. The exact method and the simple solutions 
used may depend entirely on the choice of the physi- 
cian and nurse. There is nothing that better shows 
the ability of a nurse than the condition of the tongue, 
teeth and mouth of a seriously ill patient. 

Whatever is done for the patient must be done at 
regular intervals, as prolonged periods of rest with as 
little disturbance as possible are very important desid- 
erata in pneumonia. 

When lobar pneumonia exhibits a tendency to as- 
thenia or depression, the open air treatment should be 
given in moderation, a sufficiency of pure warm air 
being supplied and the extremes of cold being avoided. 

Diet. — The quantities of protein and fuel given are 
less than the minimum health rations; the diet as a 
whole is non-putrefactive ; and it should include a suf- 
ficient quantity of the food salts needed by the body, es- 
pecially the calcium salts, of which a deficiency regu- 
larly exists in pneumonia. The purpose of the diet is to 
supply nourishment sufficient to carry the patient 
through the short period of this disease with a mini- 
mum of trouble from the alimentary tract, that region 
of special danger in pneumonia, whence may come 
general poisoning, vasomotor paralysis, nervous dis- 
turbances of the heart through reflexes and mechanic 
disturbances from distension. 

If there is gastric irritability, diarrhea or tympan- 
ites, the diet should be reduced. Peptonized milk and 
barley water, or the latter alone, may be given. Care 
should be observed in the giving of fluids so as not to 
overload the right heart. 

The following is cited by Barr to serve an adult in 
the acute stage for twenty- four hours : About 2 pints 
of milk, 2 or 3 pints of barley water, whey, or plain 
water, 6 or 8 ounces of syrup of glucose, 4 or 5 drams 
of table salt, and 1 dram of the glycerophosphate of 
calcium. If the syrup of glucose be too sweet or 



154 MEDICATION IN PNEUMONIA 

mawkish, a quarter of a pound of sugar of milk can 
be used. Later on the patient can have peptonized 
bread and milk or some infants' food, broths, raw 
eggs, jellies, cocoa or coffee, and a few biscuits. He 
can have cold water when he likes. 

General Medication.— In the beginning of this dis- 
ease, as in others, a dose of 0.15 gm. (2 grains) of 
calomel may be given, followed by a saline. 

If in spite of careful management of the diet and 
of the bowels meteorism occurs, a colon tube should 
be passed to evacuate the gas in the lower intestine. 
If the temperature is high, an ice coil over the abdo- 
men will reduce the temperature, give tone to the 
intestines, and often is more efficient than the much- 
advocated hot turpentine stupes in causing expulsion 
of the intestinal gas. Enemata containing turpentine 
are advised, but it is rarely that rectal injections will 
relieve tympanites of the small intestine. Such dis- 
tention is generally caused by paresis of the muscle 
coats of the intestine, and sometimes strychnin hypo- 
dermatically may be effective, in doses of 1/30 of a 
grain, three or four times in twenty-four hours if the 
condition is not serious. Sometimes eserin (physos- 
tigmin) given hypodermatically is effective in removing 
the condition. Aseptic ergot, injected intramuscularly, 
is sometimes of the greatest value in restoring tone to 
the intestines. 

Barr states, "There is usually a paretic condition of 
the intestinal tract, and any food decomposition is apt 
to give rise to acute dilation of the stomach and 
bowels ; when this occurs pituitary extract is the 
remedy par excellence" 

Cheinisse (Presse Medicate, April 11, 1914) reviews 
a number of articles that have been published in the 
last year or two on the therapeutic value of camphor. 
Crouzon advocates adding a little ether to camphorated 
oil to render it more fluid and thus promote its absorp- 
tion when injected intravenously; Schule uses ether 
alone for the vehicle. Subcutaneous injection of cam- 
phorated oil have been applied with apparent success 
in pneumonia by four Russian physicians and by sev- 
eral in Germany. Evidence is accumulating that cam- 
phor has a bactericidal action on pneumococci. Hotzel 



HEART IN PNEUMONIA 155 

injected subcutaneously twice a day 10 c. c. of cam- 
phorated oil in thirty cases of pneumonia and is con- 
vinced that it had a specific action. The pneumococcus 
cannot be cultivated on culture medium containing 1 
per ten thousand camphor. Rabbits inoculated with 
the pneumococcus were saved by a series of subcutane- 
ous injections of camphor without which the controls 
died. Weihrauch ascribes the antipyretic influence of 
camphor to its bactericidal action on the mixed infec- 
tion. When in pneumonia the heart action is good, 
Svoiekhotov gives the camphor by the mouth every 
two hours up to the crisis and then at longer and 
longer intervals for a few days. If the pulse is already 
up to 120, he begins at once with subcutaneous injec- 
tions of camphorated oil. The use of camphorated oil 
in heart weakness is well known. 

Rosenow has suggested the use of alkalies as of 
distinct specific action in pneumococcus infections. 
These may be given in the form of citrates diminishing 
the viscosity of the blood, and if given by mouth sup- 
plying an agreeable fluid. 

Care of the Heart. — Changes in the blood pressure, 
the heart rhythm, the quality of the heart sounds, the 
pulse tension and the respiration as manifested by em- 
bryocardia, tachycardia, dyspnea, etc. should be noted 
at once and proper corrective measures instituted. If 
stimulation of the heart is needed, it is given by Corn- 
wall according to the following plan. In the aged, in 
alcoholics, and in patients with preexisting myocardial 
disease, it is given from the beginning. In young 
adults with originally healthy hearts it is usually de- 
layed until signs of heart-strain appear, which is gen- 
erally not later than the fourth day. The first stim- 
ulant given is strychnin sulphate, in doses of one- 
sixtieth grain three to six times a day. If more stim- 
ulation is needed, tincture of strophanthus is given in 
doses of one and a half minims every four hours. The 
strychnin sulphate is increased on occasion to one- 
thirtieth grain every four hours, which is the maxi- 
mum amount of that drug permitted in this disease, 
and the strophanthus to two or three minims every 
four hours. In a large majority of cases, Cornwall 
states, more than this stimulation is not called for, but 



r 

156 ERYSIPELAS 

if it should be required, caffein citrate in doses of i 
to 3 grains every four hours is added. In cases with 
extremely low-blood pressure, epinephrin is given, 
hypodermically or by mouth. If there is an obstin- 
ately dilated right ventricle, digitalin is given hypo- 
dermically, in addition to the other heart stimulants. 
For extreme dilatation of the right ventricle threatening 
disaster, Cornwall believes venesection to be indicated. 
Whiskey, in small doses, is given to alcoholic patients 
and to the aged if they bear it well. Recent observa- 
tions seem to indicate that strychnin has not a direct 
effect on the blood pressure. 

Venesection may be indicated in the first stage of 
pneumonia in plethoric individuals, and certainly has 
saved life. Brisk purging, the stopping of pain with 
morphin, and a hot foot bath will often relieve the 
necessity for venesection. 

Vaccine Treatment. — The value of vaccines in the 
prophylaxis or treatment of pneumonia is very doubt- 
ful. The possibility of undermining the resistance of 
the patient must be considered. 

Convalescence. — In convalescence from pneumonia, 
the greatest of care should be exercised to protect the 
heart, which has been so severely overworked, from 
becoming more or less dilated and from permanent 
damage to its musculature. The increase of food 
should be carefully regulated, getting up should be 
very gradual, and all heart tire from the early ambu- 
latory condition should be carefully guarded against. 
Not only the lungs need repair after pneumonia but 
also the heart. 

A patient is rarely thoroughly over the effects of 
pneumonia for six months, and if he is able financially 
to go to a warm climate, if it is winter, or to a dry 
climate if it is some other season, and rest for two 
months after his apparent complete recovery, his lungs- 
and heart will be guarded against sequelae from pneu- 
monia. 

ERYSIPELAS 

The treatment of erysipelas has been adequately 
discussed in a recent article by Erdmaii {Jour. A. M. A., 
Dec. 6> 1914, p. 2048). He analyzed results in eight 
hundred cases seen in Bellevue Hospital, New York. 



TREATMENT OF ERYSIPELAS 157 

Etiology. — In the majority of cases of the facial 
type the point of entrance of the infection was through 
the nasal mucosa following a coryza. In others there 
were abrasions of the scalp or face, and in many 
instances, the infection began in an operative wound. 
In cases with a widespread body involvement, the in- 
fection was either migratory from the face or extremi- 
ties, or, as was common in infants, began with an 
infection of the umbilicus, an irritation of the buttocks, 
etc. Leg ulcers and wounds were the usual origin of 
infection in the extremities. 

Onset and Course. — The attack usually begins with 
chills, general malaise, headache and a rise of tempera- 
ture, which precede the appearance of the local lesion 
by from twelve to twenty-four hours. In many cases, 
however, the burning and redness of the skin are the 
first symptoms noted. 

Typical facial erysipelas which starts at the bridge 
of the nose and spreads in butterfly pattern rather 
symmetrically over the cheeks, may remain thus 
limited, but in many cases it proceeds to involve the 
ears, the forehead, the scalp and the neck, down to 
but not beyond the collar-line, except in the small 
percentage of cases which are of the migratory type. 

"Erysipelas which starts on the face or trunk and 
spreads to the extremities usually travels down both 
arms or legs with remarkable symmetry from day to 
day. 

Diagnosis. — The diagnosis should be made from the 
characteristic skin appearance, the fever, bleb forma- 
tion and desquamation. 

TREATMENT 

Internal medication should consist of such sedatives, 
stimulants or cathartics as the symptomatology may 
indicate. 

On the affected part, continuous cold compresses of 
boric acid solution may be of value. In migratory 
cases ichthyol may be applied or the areas may be 
painted with picric acid solution. Erdman found 
vaccines of little value either in shortening the duration 
of the disease, decreasing the mortality or preventing 
recurrence. 



158 TYPHUS FEVER 

Arneth (Abstr. Jour. A. M. A., Oct. 24, 1914, p. 
1 51 3) applies three or four times a day a 5 per cent, 
solution of phenol in oil. He finds this method very 
satisfactory. 

TYPHUS FEVER 

The recent developments in our knowledge of the 
etiology and transmission of this disease have been 
largely due to American investigations. These ad- 
vances have resulted from the clinical observations of 
Brill and the experimental work of several scientists, 
notably Ricketts, Anderson and Goldberger. 

Typhus fever is doubtless of microbic origin, but 
the infective agent has not yet been determined with 
certainty. Recent studies by Plotz indicate that it is 
a minute bacillus. While the etiology of the disease has 
just been determined, its mode of transmission has been 
worked out so that we are able to take reasonably 
efficient means for its prevention. It has been well 
demonstrated that the disease is communicated by the 
body louse and probably also by the head louse. This 
observation explains many puzzling features, for 
example, as McCrae remarks, the decrease of the 
danger of infection when the patient was removed 
to a hospital and the great danger to attendants in 
epidemics, to which Murchison drew attention. 

The transmission of the disease to monkeys has 
enabled it to be made the subject of exact experi- 
mental work. Typhus fever formerly was very preva- 
lent in epidemics, and also as sporadic cases, being 
known under the names of jail fever, camp fever, 
ship fever, etc., terms which indicate its close associa- 
tion with overcrowding and filth. With the progress 
of sanitary science, the prevalence of the disease 
decreased until it appeared to have vanished with the 
march of civilization, especially in this country. 

In the United States the disease, in its typical form, 
has been found usually in ships coming into our sea- 
ports. A mild form of the disease has been discovered 
even in our farthest inland cities. It is important that 
the existence of this mild form should be borne in mind 
not only as explaining many puzzling cases but also as 
the possible source of epidemics when the organism 
may assume unusual virulence or the opportunity for 



SYPHILIS 159 

transmission be unusually great. Clinically, the dis- 
ease displays the absence of a characteristic course 
with the exception of the petechial eruptions. It is 
a general fever, in its severer forms, presenting the 
characteristic typhoid state. It is a striking fact that 
this typhoid state is observed with comparative rarity 
in modern epidemics of ordinary typhoid fever. The 
incubation period is put usually from four to fourteen 
days. The onset is abrupt, with headache, general pains, 
and frequently with one or more chills. The eruptions 
appear from the third to the fifth day and the face 
is much reddened and swollen but rarely shows the 
characteristic spots. The temperature remains high, 
usually from 104 to 105 throughout the attack. The 
fever terminates by lysis in a great proportion of cases, 
contrary to the general belief, although several authors 
describe only a crisis lasting from 12 to 48 hours ; this 
is a frequent termination of the disease. The duration 
is usually from twelve to fifteen days. 

The prevention of the spread of this disease is a 
comparatively simple problem, although, as experience 
in the present war shows, it may be very difficult of 
accomplishment. It consists essentially in the destruc- 
tion of vermin. This involves, of course, at the same 
time the removal of filth, the cleaning of the inhabi- 
tants, and the prevention of accumulation of waste. 
The treatment should be symptomatic following the 
suggestions made for other infections. 

SYPHILIS 

The finding of the organism of syphilis, the tre- 
ponema pallidum, in the initial lesion either by staining 
or the dark stage methods is, of course, the conclusive 
evidence of a syphilitic infection. The diagnosis of 
the disease must be considered, however, as it applies 
to various groups, the patient with a sore, the patient 
with a sore and an eruption, the patient with an erup- 
tion or sore throat or both, the patient with nothing 
visible and nothing palpable, and the patient who 
comes with a typical case of general paresis, or tabes 
or cerebrospinal syphilis. In making a diagnosis the 
physician should use every available diagnostic aid, 
including the Wassermann test, and perhaps also the 
luetin test. Just what reliance should be placed on 



160 SALVARSAN IN SYPHILIS 

the Wassermann test is a question worthy of considera- 
tion. In the presence of good clinical evidence of the 
presence of syphilis, a negative reaction should receive, 
probably, scant consideration. Treatment might better 
be instituted and repeated Wassermann tests made 
later in an attempt to confirm the diagnosis. A posi- 
tive reaction in the absence of reliable clinical evidence 
seems to indicate the need of further inquiry into the 
history of the patient and repeated Wassermann tests 
while instituting treatment. 

EARLY TREATMENT 

The patient should be instructed regarding the 
observance of good general hygiene. A nutritious 
simple diet, total abstinence from alcohol and tobacco, 
a proper amount of fresh air and physical exercise are 
essential to the tolerance of the disease and the strenu- 
ous treatment. 

THE CARE OF PRIMARY LESION 

Ordinarily it will not be necessary to cauterize the 
primary lesion. Ordinary cleanliness and protection 
should be used. Whatever the dressing it should not 
be irritant lest it cause inflammation of the surround- 
ing tissues. If the lesion is syphilitic, it will heal read- 
ily following internal treatment. 

SALVARSAN AND NEOSALVARSAN 

The use of salvarsan and neosalvarsan early in the 
disease is productive of an early disappearance of 
external lesions and if sufficiently early will often 
prevent the appearance of such secondary signs as the 
eruption, sore throat, alopecia, systemic disturbances, 
etc. The dose of salvarsan should be graduated to 
the weight of the patient. It may be administered 
intravenously, intramuscularly or subcutaneously, the 
former method being by far the most popular one. 
Care should be taken in the technic; the preparation 
of the drug; the choice of site of injection, etc.; to 
prevent such complications as thrombosis, phlebitis, 
sloughing of tissue, embolism, or optic atrophy. An 
optic neuritis is generally considered to be a contraindi- 
cation to the use of these drugs. The neosalvarsan is 



MERCURY IN SYPHILIS 161 

more easily prepared than salvarsan but has been 
determined to be of about one-third the strength. 
Treatment with salvarsan should be combined with 
mercury in various preparations, and the Wassermann 
should be a guide in the intensity of the treatment. 

MERCURY 

In those cases in which it seems preferable to ad- 
minister mercury internally, the preparations best 
adapted for use are the protiodid, the biniodid, the 
bichlorid, and mercury with chalk. The protiodid may 
be given in doses of 0.015 to 0.02 gram (J4 to T /z 
of a grain) three or four times a day, the smaller dose 
and less frequently repeated if the medicine causes too 
frequent movements of the bowels. When this form 
of treatment is adopted, it should be employed con- 
stantly over as long a period as eighteen months. 

The inunction treatment is an efficient method of 
attacking the disease if it is done in an efficient manner. 
As a general rule the patient cannot be trusted to con- 
duct this treatment alone. A course of inunction 
treatments may consist of 20, employing 4 grams (a 
dram) of the official mercurial ointment, rubbed well 
into the different parts of the body, once a day, the 
treatment lasting at least 15 minutes. A turkish bath 
or "body bake" at least once a week is advisable. 

A third method of administering mercury which is 
probably most popular in recent years, is that by 
intramuscular injection. The most favorable site is 
usually the gluteal region. The lower part of the but- 
tock should be avoided in order that the patient may 
sit without undue discomfort; the center of the gluteal 
region should be avoided because of the danger of 
puncturing gluteal vessels or the sciatic nerve. Of 
course, the two sides should be used alternately in 
giving a series of injections. 

The best syringe for these injections is one made 
entirely of glass, of small caliber, and graduated to 
fractions of a minim, such as is made for tuberculin 
injections. The needle should be from \y 2 to 3 inches 
in length. Steel needles are much cheaper than those 
of iridoplatinum, but are likely to be corroded by solu- 
ble mercurial salts. 



162 MERCURY IN SYPHILIS 

The fluid is drawn into the syringe, and any air 
bubbles carefully expelled. Then the skin having been 
properly cleansed, the needle is thrust through it in a 
perpendicular direction so as to reach the required 
depth at a single stroke. Next assure yourself that 
the point of the needle does not lie in a vein, by 
detaching the barrel and watching the lumen for a 
moment. If blood flows through the needle, make 
another puncture ; otherwise replace the syringe and 
proceed with the injection. It is not necessary to mas- 
sage the injected mass. The most careful practice is 
to make the injections with the patient lying face 
downward, but those well accustomed to the procedure 
may be properly injected standing, provided they are 
required to relax the gluteal muscles. The dressing 
of the puncture is necessary only when bleeding 
occurs. 

The preparations of mercury used in this way in- 
clude both soluble and insoluble salts. The most use- 
ful soluble salts are the benzoate and the biniodid. 
These are well tolerated and efficient, and all others 
are superfluous, in the opinion of Levy-Bing, as ex- 
pressed in his monograph on intramuscular mercurial 
injections, published in Paris, in 1909. The salts men- 
tioned are used in 1 or 2 per cent, solution, in isotonic 
saline solution. The insoluble salts most frequently 
used are the basic salicylate, calomel and grey oil, the 
latter being an emulsion of metallic mercury in an 
oily vehicle. "The vehicle for calomel and the salicyl- 
ate may be either an oil or a mucilage. The combina- 
tion recommended by Levy-Bing of 3 parts of anhy- 
drous wool-fat with 7 of white liquid petrolatum has 
proved satisfactory. It is most important that all 
these substances be pure and neutral. Calomel should 
be especially pure, and should be washed in boiling 
alcohol before being incorporated with the vehicle, 
and both calomel and mercury salicylate should be 
finely divided by prolonged trituration with the men- 
struum. 

Both of these preparations may be sterilized in a 
water-bath ; the grey oil, however, is spoiled by heat 
and consequently must be prepared from sterile mate- 
rials with sterile utensils and under aseptic conditions. 
As the process consists of a trituration of the mercury 



MERCURY IN SYPHILIS 163 

with the wool-fat for at least two hours, it may be 
imagined what a formidable task this is. If carefully 
guarded from contamination these injection fluids 
need not be repeatedly sterilized." (Pulsford) 

Injections of soluble salts should be used when rapid 
mercurialization is required. They may be used at the 
beginning of treatment. The insoluble salts are in- 
dicated in the routine treatment of most cases. Cal- 
omel is usually more effective in urgent cases, but it 
causes too much pain to use in ordinary cases, in which 
the salicylate and the grey oil are preferable. 

In beginning treatment it may be necessary to give 
an injection every day for a few days; but afterwards 
a weekly injection will be sufficient. 

The average weekly dose is 1 grain of metallic mer- 
cury, 1 1/6 grains of calomel, or 1^ grains of salicyl- 
ate of mercury. 

Among the disadvantages of this form of treatment 
should be noticed the fact that they are more or less 
painful. With the soluble salts the pain begins at 
once and lasts for from 1 to 6 hours. With insoluble 
preparations it begins within an hour, and lasts from 
two to five days. The pain is most severe after cal- 
omel, and least so after grey oil, which is often entirely 
painless. 

Hard masses of exudates, known as nodes, some- 
times forms about the injected mass. These often 
retain a part of the injected fluid, which may subse- 
quently be suddenly absorbed. 

Embolism sometimes results from the injection of 
the fluid into a vein. Although this has rarely, if ever, 
proved fatal, it should be avoided. Abscesses rarely 
occur if the injections are properly administered. 

Whatever method of administering mercury is 
adopted, certain general hygienic rules must always be 
observed. The teeth must be put into good condition 
and the mouth must be kept clean. Chewing tobacco 
must be absolutely interdicted. Moderate smoking and 
temperate drinking may be allowed to those who are 
accustomed to the use of tobacco and alcoholic drinks, 
unless some special condition renders it advisable to 
discontinue their use entirely. 



164 IODIDS IN SYPHILIS 



IODIDS 



While the iodid of potassium is the salt most gener- 
ally used, the sodium iodid is perhaps preferable, since 
the sodium element is not as debilitating to muscle 
tissue as is the potassium. This is especially true of 
the cardiac muscle. Hence when large doses must be 
given, or when the doses must be prolonged, the iodid 
of sodium should be preferred. This salt also some- 
times seems less likely to disturb the stomach. 

The symptoms of iodism should be avoided if possi- 
ble. These symptoms are coryza, frontal headache, 
reddening of the eyelids, a strong, metallic taste in 
the mouth, sometimes a profuse flow of saliva and 
gastric indigestion. It is unimportant whether the 
iodid is ordered largely diluted or in saturated solution, 
but it should never be ordered in any syrupy, nasty 
mixture. It is preferably administered in milk or in 
an alkaline water. It is generally best administered 
after a meal, theoretically best an hour after meals, as 
it slightly inhibits digestion. When an iodid is admin- 
istered the yellow iodid, i. e., the protoiodid, of mer- 
cury should not be the salt selected for simultaneous 
administration, as it is likely to be chemically changed 
into the biniodid (red iodid) of mercury, which salt 
would then be present in a poisonous quantity. The 
following prescriptions may be used : 

Gm. 

I£ Sodii iodidi 251 

Aquae destillatae, q. s. ad 

saturandum , q. s. ad sat. 

M. et Sig. : Five drops with milk or water, three times a 
day, after meals. 

Each minim of this solution represents a grain of 
the drug.* The dose should be gradually increased 
until the amount given is deemed sufficient. 
Or 

Gm. or c.c. 

I£ Potassii iodidi 10] or 3 iiss 

Aquae 100| AS iii 

M. et Sig. : One-half a teaspoonful, in milk or water, three 
times a day, after meals. 

* The statement frequently made that a drop of a saturated solution 
of potassium or sodium iodid represents a grain of the drug is apt to 
lead the physician into error, as the size of a drop varies with the size 
and nature of the container from which it is dropped. See The Journal 
A. M. A., Oct. 21, 1908, p. 1526. 



IODIDS IN SYPHILIS 165 

The iodids have been given in enormous doses, espe- 
cially where gumma of the central nervous system has 
been diagnosed. It is a question whether such large 
doses are justifiable and even whether such large doses 
are of advantage. It is probable that ordinary fair- 
sized doses can do as much chemical and biologic good, 
as any dose however large, in causing resorption of 
connective tissue formations, the blood and cells being 
only able to absorb and utilize a certain amount of 
iodin. In other words, enormous doses are illogical 
and are probably rapidly passed out of the body by the 
excretions. 

Jobling and Petersen (The Journal, November 28, 
1914, p. 1931), say: "Clinical experience teaches us 
that in the tertiary stage of syphilis iodin is almost a 
specific in bringing about the amelioration of symp- 
toms, and the disappearance of lesions, and yet little 
is known concerning the means by which these results 
are obtained. 

"As experimental work and clinical observations have 
demonstrated that the iodids do not destroy the infect- 
ing organism, we must assume that the results obtained 
are due to the power the iodids possess of causing 
resolution of the lesions present. That this actually 
occurs will be attested to by every clinician of experi- 
ence. It is due to the fact that the unsaturated fatty 
acid radicals which inhibit autolysis, have become satu- 
rated with iodin. As soon as this occurs, the ferments 
which are present, or which may be brought in, become 
active, autolysis takes place, and the necrotic tissue is 
absorbed. Here, also, the local action of the ferments 
is made less difficult by the reduction of the anti- 
enzyme in the circulating blood. It must be borne in 
mind that the iodids are not as effective in the earlier 
stages of syphilis when necrosis of tissue is not so evi- 
dent. 

"If the above interpretation of the action of iodin is 
correct, it gives the clinician a rational idea of what 
he is accomplishing when he gives iodids to a patient 
in the tertiary stage of syphilis. According to this 
view, iodin neutralizes the action of the agents which 
prevent resolution and absorption of the diseased or 
necrotic tissue, and at the same time lays bare to the 



166 SYPHILIS OF THE NERVOUS SYSTEM 

action of the real germicidal agent the infecting organ- 
ism which previously had been protected by the ne- 
crotic tissue. With the exposure of the infecting 
organism, such agents as mercury and salvarsan would 
be much more effective. " 

CARE OF THE MOUTH 

During the mercurial treatment the patient should 
drink plenty of water to promote the activity of all the 
organs of excretion. The mercury will probably soon 
cause sufficient or even perhaps too frequent move- 
ments of the bowels. The care of the mouth, teeth 
and gums is important, and the patient can not be too 
carefully instructed in this matter. Any alkaline wash, 
or, if there are any erosions, peroxide of hydrogen ap- 
plications, or a mouth wash of alcohol one part and 
water three parts, or a potassium chlorate mouth wash, 
and occasionally tannic acid washes and gargles are 
useful. Ulcerations in the mouth and throat will often 
heal rapidly after one or two applications of a 25 per 
cent, solution of nitrate of silver. Without ulceration 
in the mouth and throat the mucous membrane may 
be kept healthy by a thorough cleaning of the teeth 
two or three times daily, and the cleansing of the 
mouth and throat with alkaline solutions. 

The patient should be thoroughly instructed as to the 
danger of his infecting others and the manner of such 
infection, as by napkins, towels, drinking cups, spoons, 
forks, or kissing. Such instructions should be most 
explicitly given if there are mucous patches in the 
throat. 

SYPHILIS OF THE NERVOUS SYSTEM 

Swift and Ellis (Archives of Internal Medicine, Sep- 
tember, 1913) suggested what is known as the auto- 
serosalvarsan method of treating syphilis of the ner- 
vous system. Almost coincident with this discovery 
Noguchi was able to demonstrate the presence of the 
Spirochaeta pallida in the brain tissue of general par- 
etics. Briefly the method consists in injecting salvar- 
san intravenously, waiting one hour, withdrawing 40 
e. c. of blood, allow it to coagulate, then centrifugalize. 
The following day pipette off 12 c. c. of serum, and 
dilute with 18 c. c. of normal saline. Heat to 56 C. for 



SYPHILIS OF THE NERVOUS SYSTEM 167 

one half hour. After lumbar puncture withdraw the 
spinal fluid until a pressure of 30 mm. is reached. The 
barrel of a 20 c. c. all glass syringe is connected to the 
needle by means of a rubber tube about 40 cm. long. 
The tubing is then allowed to fill with cerebrospinal 
fluid so that no air will be injected. The serum is 
then poured into the syringe and allowed to flow 
slowly into the subarachnoid space by means of grav- 
ity. At times it is necessary to insert the plunger of 
the syringe to inject the last 5 c.c. of fluid. 

Of this method Weisenburg {Jour. A.M. A., March 
20, 1915, p. 975) says: "The Swift-Ellis method 
reacts differently on different patients. I have not 
had serious complications, although one patient was 
unable to void urine for forty-eight hours and had to 
be catheterized. I have learned never to give a second 
spinal injection until the patient has altogether re- 
covered from the previous one. Nearly always it 
takes a patient a longer time to recover from each 
successive injection. 

"As to citation of more definite cases and results : 
In spinal syphilis, cerebrospinal syphilis and cerebral 
syphilis, the results have been splendid and better than 
could have been obtained from mercury alone. Prac- 
tically all symptoms disappear which are dependent 
on the meningeal irritation, and only those remain 
which are the result of implication of the parenchy- 
matous structure, as happens when a thrombosis of a 
vessel occurs with a consequent necrosis of the part, 
or what is more common, when there is an atrophy 
of the nerve cells and the fibers coming from them. 

"In tabes my results have been good only in those 
cases in which there has been great meningeal irri- 
tation, that is, the pains have lessened, the patients 
have slept better and the general condition has 
improved vastly, but there has not been a return of 
knee jerks, pupillary reflexes or any of the symptoms 
which are dependent on permanent destruction of 
nervous tissue. I found that the Swift-Ellis treat- 
ment cannot always be given in tabes because the 
reaction is terrific in some instances, the pains being 
excessive, the patient having very marked pyrexia, 
and in one patient the reaction was so profound that 



168 SYPHILIS OF THE NERVOUS SYSTEM 

ii took him about a month to recover. One cannot 
expect in this disease to cure what has already been 
destroyed, but it is possible to prevent further active 
inflammation, at least so far as those pathologic 
processes are concerned which are the result of the 
spirochetes located within the vessels and meninges. 

"In paresis my results have not been good, but as has 
been previously stated, it is impossible in early pare- 
sis to make a differential diagnosis from cerebral 
syphilis. Therefore it is important to institute prompt 
and vigorous treatment in all early cases. 

"As I have tried to emphasize in the early part of 
my paper, it is as important for the welfare of the 
patient to know when not to institute treatment. In 
a patient in whom the cell count is small and the 
Wassermann reaction is either faintly positive or 
negative in the cerebrospinal fluid, the Swift-Ellis 
method should never be employed, although salvarsan 
may be given intravenously a number of times, but 
the effects should be carefully watched, and if the 
patient does not react well, this treatment should 
cease. If, on the other hand, the patient improves, 
the treatment should be kept up." 

The consensus of opinion seems to be that this 
method has a distinct field in the treatment of nervous 
syphilis. 

Ravaut and many others have injected neosalvarsan 
directly into the cerebrospinal fluid in small dosage 
and have at times achieved remarkable results. There 
have however been numerous reports of disaster and 
the method must still be considered as in the experi- 
mental stage. Weisenburg says : 

"I have used the direct injection of neosalvarsan in 
the spinal canal. In one instance it was given for 
me in a case of general paresis, and the reaction was 
milder than in some of the Swift-Ellis injections pre- 
viously given. A subsequent injection in the same 
patient caused his death within forty-eight hours. As 
a consequence, I am afraid of this method and have 
not used it since. I have had no experience with the 
mercurial injection into the spinal canal as practiced 
by Byrne of Baltimore." 



TUBERCULOSIS 169 

This field is a new one and the literature is growing 
rapidly. No doubt the methods described represent a 
great advance in the treatment of syphilis of the ner- 
vous system and the physician should endeavor to 
follow closely the new reports on this subject. 

TUBERCULOSIS 

Under the general title of tuberculosis are included 
the various pulmonary forms, abdominal forms, tuber- 
culosis of the bones, glands and other organs of the 
body. This is a disease of civilization and hence due 
to the congregation and crowding of mankind into 
small regions, as cities. Thousands of persons suffer- 
ing from pulmonary tuberculosis are walking our 
streets and expectorating billions of tubercle bacilli 
daily. 

ETIOLOGY 

The discovery of the tubercle bacillus by Robert 
Koch, in 1882, and the proof that this bacillus was the 
cause of tuberculosis, changed the established belief 
that tuberculosis was hereditary to the belief that it 
must always be acquired. This is of course a most 
constant fact, but the part that heredity plays in the 
development of tuberculosis, in furnishing proper 
ground in which the bacillus may grow, or in offering 
a condition of low-grade immunity against this disease, 
is progressively becoming more prominent. A human 
fetus can be born with tuberculosis, but comparatively 
few such cases have been recorded. If one were 
roughly to estimate the number of such authentic in- 
stances it might not be far from one hundred, and in 
most of these the mother was the tuberculous parent. 

Tubercle bacilli have rarely been found in the milk 
of an infected mother. Therefore, direct infection 
from this source is improbable. It is possible, how- 
ever, that toxins from the tubercle bacillus or from a 
secondary infection of the mother may be eliminated 
in the milk and cause, in the child, gastro-intestinal 
disturbance, fever and emaciation. It is improbable 
that the milk could furnish any substance that would 
render the child immune to tuberculosis. The thera- 
peutic conclusion is positive that a tuberculous mother 
should not nurse her child, not only for the child's 



170 ETIOLOGY OF TUBERCULOSIS 

sake, but also for her own, as the mother rapidly 
grows worse through the nutritional loss caused in 
producing the milk. 

Statistics show that the person who is underweight 
and has a family history of tuberculosis is more likely 
to develop the disease than one who is underweight 
without a family history of tuberculosis. On the other 
hand, a person of full weight or overweight, whatever 
the family history, while not precluded from the possi- 
bility of developing tuberculosis, is much less likely to 
have it than one who is underweight. Also, one who is 
underweight is more likely to develop tuberculosis than 
a person of normal weight. Whether or not, the 
majority of underweight persons harbor tuberculosis 
germs and such a condition predisposes to underweight 
has not been demonstrated, but it is quite possible. 

As is apparently true of most germ diseases, a race 
that has but recently acquired the disease is more sus- 
ceptible to its inroads, and has the disease more 
actively than a race that has long suffered from it. 
Also, a change from outdoor life and a dry, clean air 
environment to indoor or to city life, or to a region 
where the air is damp or dust laden, predisposes to 
the development of tuberculosis. 

These bacilli almost invariably gain entrance to the 
system by one of two ways : by inhalation, or by swal- 
lowing. A germ that is so constantly present in almost 
every community of civilized peoples must be breathed 
and swallowed by most persons. Something in the in- 
dividual must tend to kill these germs before they 
acquire a home, that is, before they congregate in suf- 
ficient numbers to perpetuate themselves. Nothing 
probably tends more to prevent the acquirement of 
this disease than general good health, which especially 
means health of the upper-air-passages and throat, the 
absence of bronchial catarrh, healthy tonsils, a normal 
digestion and healthy intestines. The tubercle bacillus 
probably cannot find a living chance unless there is 
some disease, injury or chronic disturbance in one of 
the parts of the body mentioned, and unless a suffi- 
ciently large number of them are inhaled or swallowed 
at once, so as almost to overwhelm the person's ability 
to destroy the germ. Of course, it is possible and 
perhaps probable that, although this disease gives no 



ETIOLOGY OF TUBERCULOSIS 171 

immunity, a patient in whom the disease has been 
arrested or in whom the disease once active is now 
chronic or more or less latent, may produce, or have 
already circulating in the body-fluids, enzymes that may 
destroy the tubercle bacillus more readily than is possi- 
ble in one who has never had the disease. 

Perhaps many conditions that we have termed 
causes predisposing to tuberculosis may really stim- 
ulate to activity latent tuberculosis or a tuberculous 
focus harbored and concealed somewhere in the 
patient's body. Whichever of these two suppositions 
may be correct, we recognize that a patient is likely to 
acquire, or having acquired, at least may develop an 
active tuberculous process when he is anemic; when 
he is under weight ; when he is continuously overf a- 
tigued; when he has a tendency to recurrent colds, 
especially to recurrent bronchitis ; when he does not 
quickly recuperate from any simple acute infection, 
whether it be grip, measles or whooping-cough, etc., 
or when he has suffered from a more serious acute 
infection, such as some prolonged septic process or 
typhoid fever, and especially when he does not recover 
quickly from a pneumonia or a pleurisy with effusion. 
Pleuritic effusions are considered as perhaps generally 
tuberculous in origin. None of the surrounding pre- 
disposing causes, such as unsatisfactory housing and 
occupations that are dangerously dusty, need to be con- 
sidered here. 

A child is considered predisposed to the development 
of tuberculosis, or perhaps already has a latent tuber- 
culosis, if he is pale, has a tendency to eczemas, or has 
enlarged tonsils or postnasal adenoids, and especially if 
he has enlarged cervical glands. Caries of the teeth is 
also perhaps a predisposing cause, as decayed teeth 
may harbor all kinds of germs. Therefore to allow 
caries of a child's first teeth to persist, because they 
will soon be lost with the eruption of the second teeth, 
constitutes serious neglect. An enlarged cervical gland 
probably always shows that an infection entering 
through the tonsil has invaded the next fortress 
of protection, namely, the cervical glands. If the 
infection is tuberculosis, the gland may be actively 
tuberculous, and evident tuberculous adenitis is the 
condition. Much more frequent and not evident, but 



172 MEASURES TO DECREASE TUBERCULOSIS 






often found by good roentgenograms of the chests of 
children, is the involvement of the bronchial glands 
by the tuberculous germ having perhaps first gained 
entrance through the tonsils, and this without any 
involvement of the cervical glands. In fact, it has 
been repeatedly demonstrated that perhaps the major- 
ity of children affected with tuberculosis have the 
initial lesion in the tracheobronchial and hilus glands. 
The bovine tuberculosis is frequently transmitted to 
children through milk by way of the intestine has for 
some years been thoroughly established, and it has 
been shown that many instances of glandular tuber- 
culosis are due to this type of bacillus. General tuber- 
culosis rarely, but udder tuberculosis almost always, 
infects milk with tubercle bacilli. The frequency with 
which bovine-tuberculosis-infected milk causes tuber- 
culosis in children is still more or less a subject of 
dispute. Many experiments have shown that the gas- 
tric juice does not necessarily, if ever, kill the tubercle 
bacillus. 

MEASURES THAT WILL CAUSE A DECREASE IN THE INCI- 
DENCE OF THIS DISEASE 

These may be enumerated as, primarily : 

1. General instruction in hygiene and in the con- 
ditions that predispose to this disease. 

2. Tenement-house laws to prevent overcrowding. 

3. Sunlight. 

4. Open windows, verandas and roof-gardens. 

5. Municipal breathing-spaces ; parks, playgrounds, 
etc. 

6. Proper ventilation of all churches, theaters, halls 
and assembly rooms. 

7. Open-air schools, or open-window schools. 

8. Laws prohibiting spitting on the streets and in 
buildings. 

9. Better factory sanitation ; better methods of 
cleaning public buildings and public conveyances. 

10. Special laws against the dissemination of dust 
in factories, foundries and all occupations in which it 
may be inhaled. 

11. Better hygiene and improved buildings for all 
general hospitals, prisons and jails. 



PRETUBERCULOUS SYMPTOMS 173 

12. Better laws for the more scientific control of 
tuberculous cattle, and compulsory cleaning and im- 
proving of cow-barns and farms used for producing 
public milk-supplies. 

13. Certification or pasteurization of all milk used 
for infant-feeding. 

Personal preventive measures are : 

1. Compulsory report of every case of tuberculosis. 

2. Careful instruction of the family in the care of 
the tuberculous person, if he is to remain at home. 

3. Careful personal instruction of the patient, if he 
is at an age to receive it, as to the possible methods of 
communicating the disease to others. 

4. Sanatoriums for incipient cases of pulmonary 
tuberculosis. 

5. Isolation hospitals for advanced tuberculosis 
patients whose home surroundings are inadequate. 

6. Skilled dispensary care of ambulatory cases and 
visiting nurses for "follow-up" work. 

7. Sanatoriums or rest-hospitals for joint and bone 
tuberculosis ; these are of special value when located 
at the seaside. (The value in glandular tuberculosis of 
seaside sanatorium or veranda rest-cures should also 
be recognized.) 

8. Careful instruction to reduce the morbid fear of 
other members of the family, and for the mental com- 
fort and happiness of the patient. This should be 
given, both by the board of health and by the attending 
physician, to the effect that the disease is not contagi- 
ous, and that if the instructions urged are properly 
carried out the probability of acquiring the disease 
from the patient is practically nil. 

PRETUBERCULOUS SYMPTOMS 

The earlier we recognize the signs of probable or 
even possible tuberculosis, the better, as prevention is 
far easier than cure, though a cure is probable all 
through the first and second stages, and possible even 
in the third stage of the disease. 

The conditions which predispose to this disease have 
already been enumerated. Besides correcting these 
conditions, we should use every means to build up the 
general system by tonics, outdoor life, change of clim- 



174 EARLY SYMPTOMS IN TUBERCULOSIS 

ate, and by proper tepid or cold water sponging in the 
morning which causes the skin so to react that colds 
are not readily acquired. 

At a very early stage there may be no lung signs, 
and it may be impossible to determine whether or not 
the bronchial lymph-nodes are enlarged or diseased. 
There are loss of weight, more or less gastric disturb- 
ance, pallor, lassitude and vasomotor disturbances 
shown by cold hands and feet; or the latter may be 
intermittently very hot and dry. There is generally 
a history of progressive loss of weight, irregular chest 
pains, shallow breathing, dry cough, especially on deep 
inspiration, and, most important symptom of all, an 
afternoon or evening rise of temperature, not explain- 
able by any tangible cause (although it must not be 
forgotten that occasionally such a temperature can be 
of nervous origin). Gastric indigestion, with loss of 
appetite, is often an early symptom of pulmonary 
tuberculosis. An anal fistula is generally secondary, 
^nd is not often primary to the lung lesion, and the 
discharge from it may contain tubercle bacilli, as well 
as staphylococci and streptococci. There may be some 
other chronic suppuration present, as a middle-ear 
catarrh. While anemia is generally an early symptom, 
in the early stages there may be an increase in the 
number of the red blood-corpuscles. Amenorrhea, 
even without anemia, in girls and women is generally 
an early symptom; but women can complete one, or 
even two pregnancies while tuberculous. 

While we are studying every symptom, and the 
lung symptoms are so few, to ascertain whether the 
patient really is tuberculous, a personal history of 
much sickness, especially colds, enlarged glands, 
chronic joint and tendon swellings or recurrent 
diarrheas, even if there has been no actual pulmonary 
consumption in the immediate family, renders the 
tendency, and hence probability of tuberculous infec- 
tion, much greater. Stiller's Habitus Enteroptoticus is 
probably due to a tuberculous infection. 

In making the physical examination it should be 
remembered that it has long been decided that the flat, 
broad chest, contrary to previous belief, is less likely to 
be tuberculous than the rounded, barrel-shaped chest. 
Also, the chest circumference in the nipple line should 



TEMPERATURE IN TUBERCULOSIS 175 

measure anatomically half the height of the person. 
The expansion, unless the patient is abdominally 
obese, should be from 3 to 4 inches ; 2y 2 inches is 
too small an expansion for a young adult. The in- 
spection of the chest may show a lagging of one side 
during expansion, which may, however, be most notice- 
able with the finger-tips placed under the clavicles. 
This sign is very suggestive. The typical impaired 
percussion-note, imperfect breeziness of the inspir- 
atory murmur, lessened depth, slight jerky inspiration, 
slightly prolonged, expiration, slightly increased vocal 
resonance and localized rales, either dry or moist, with 
increased muscle resistance over a diseased area, with 
pleuritic pains in the upper part of the chest or be- 
tween the shoulder-blades, are all too well understood 
to require elaboration. Very suggestive is the axillary, 
dripping perspiration during examination. Also sug- 
gestive is the little dry cough during the required in- 
creased inspiratory effort. This dry cough, hardly 
noticed by the patient, has probably been observed for 
weeks, if not longer, by the patient's family. 

A study of the temperature of the suspected person 
is important; the temperature should be taken every 
three hours during the day for several days, or at least 
at 8 o'clock in the morning, at 4 in the afternoon, and 
at 8 in the evening, if not more frequently. A recur- 
rent rise of temperature in the afternoon or evening, 
without any assignable cause, is almost pathognomonic 
of a latent tuberculosis becoming active. Some patients 
who show no temperature at rest will have quite a rise 
of temperature on the least exercise. Temperatures 
taken under the tongue are not so accurate as when 
properly taken in the axilla. Many a patient whose 
temperature is normal by the mouth will be found to 
have a higher temperature in the axilla. Of course, 
the most accurate is the rectal tempera f ure, but this 
is rarely necessary for the diagnosis. An increased 
pulse-rate, over a hundred, with or without rise of 
temperature, is very suggestive, and if the pulse-rate 
is higher than the temperature would call for, the like- 
lihood of tuberculosis is increased. 

A slight hemorrhage of arterial blood always 
causes the laity to suspect phthisis, and the suspicion is 
quite generally correct. Hemorrhages can occur from 



176 SPUTUM EXAMINATION 

the blood-vessels of the throat and larynx, although 
they are generally very small in amount, and most fre- 
quently venous, and many a patient has been con- 
demned to treatment for tuberculosis on account of a 
perfectly simple throat hemorrhage. 

The occurrence of typical night sweats, that is, cold 
sweats toward morning, is a frequent and suggestive 
symptom of tuberculosis ; but patients who have been 
weakened by illness, overwork, or overexertion may 
have this symptom for a short time, although it should 
always create suspicion. 

A rarely noted symptom of tuberculosis, which may 
occur early in the disease or not until later, is atrophy 
of the mammary gland on the affected side ; also, the 
hand and foot may be colder on the side affected, or 
if they are hot and dry, may be warmer than on the 
other side of the body. Conjunctivitis, blepharitis and 
an inequality of pupils, with dilatation of the pupil on 
the same side as the affected lung, have been noted. 
The skin of the tuberculous patient is often dry, and 
may be rough and sallow ; there may be increased pig- 
mentation, especially around the nipple on the diseased 
side, and there may be chloasmic spots. Bright red 
spots on the cheeks, and the glistening eyes occurring 
in the late afternoon, with the hands dry and hot, are 
almost pathognomonic. At other times of the day 
there is pallor, with the veins prominent all over the 
body; the face looks sad, and there is languor and a 
rapid, collapsing pulse. These are all signs that may 
occur at an early period. 

Before deciding that the sputum of a suspected 
patient, or a patient who has incipient tuberculosis, is 
free from tubercle bacilli, several examinations must 
be made. The sputum may be found free from bacilli 
on several days, and then on the last day of the exam- 
ination found to be loaded with them. The number of 
bacilli found has no great bearing on the prognosis of 
the disease. On the other hand, if large numbers of 
tubercle bacilli continue to be present after consider- 
able periods, probably cavitation is either present or 
developing. The prognosis can hardly be made from 
the character or appearance of the tubercle bacilli, 
although it has been thought that large numbers of the 



TUBERCULIN TESTS ' 177 

smaller tubercle bacilli show greater activity of the 
disease. 

A fluoroscopic examination of the chest will often 
reveal, even before clouding of any portion of the lung 
occurs, a diminished excursion of the diaphragm on 
the affected side. This is very suggestive of tubercu- 
losis. Roentgenograms may show areas of beginning 
lung trouble as well as diseased bronchial glands. Be- 
sides the skin tuberculin tests, the conjunctival test and 
the interdermal test, all of which are more or less 
reliable, a positive diagnosis can generally be made by 
injecting the original tuberculin subcutaneously. 

A number of substances can produce a reaction in 
tuberculous patients similar to that from tuberculin. 
Nucleoproteins, cinnamic acid and some alkaloids can 
do this. 

The tuberculin used in making the test for tubercu- 
losis is a purified extract prepared from tubercle 
bacilli. The details of its preparation need not be 
described here. Its injection causes a leukocytosis 
and stimulates the production of ferments, especially 
in the cells and tissues immediately surrounding the 
tubercles. These ferments then act on the poisons that 
have been produced by the tubercle bacilli and have 
accumulated in the tubercles. 

The fever reaction is due to the toxins set free from 
the tubercles and to the action of the enzymes on these 
toxins. If some form of tuberculin is used for cur- 
ative purposes, the reactions will become less and less, 
as more of these sealed-in toxins are set free. Also, 
reaction may be less as the system becomes less sensi- 
tive and hence immune to the irritation of these toxins. 
It can readily be seen that if too large doses of tuber- 
culin are administered, either as a diagnostic test or as 
a curative treatment, such a large amount of these 
toxins might be liberated as to cause an intense fever 
reaction, to the disadvantage of the patient. Also, it 
is quite possible by such treatment to liberate live 
tubercle bacilli and cause general infection. Hence the 
greatest possible care should be exercised in using 
tuberculin, either as a test or as a treatment, and the 
first doses should be of minimum amounts. 

As tubercle bacilli are not readily killed by leuko- 
cytes, the latter surround the mass of bacilli and disin- 



178 VALUE OF TUBERCULIN TESTS 

tegrating and caseous material; the resulting lesion is 
called a tubercle. The fight, then, of enzymes and 
toxins goes on between the two opposing factions. 
Some of the leukocytes and some of the bacteria die, 
with the production of toxins and enzymes. If these 
are liberated by the local inflammatory process the 
fever reaction and the other concomitant symptoms 
occur in the person if sufficient amount of the toxin 
circulates in the blood. Every tubercle that breaks 
down and is evacuated into the bronchial tubes and 
expectorated, is a step toward recovery. This satis- 
factory process, however, cannot go on without a 
general disturbance of the patient, with loss of appe- 
tite, loss of weight and emaciation, and it becomes a 
question whether the person can stand the disease until 
the tubercles are evacuated, and whether or not such 
evacuation will produce cavitation. The object of a 
tuberculin treatment is to aid the patient slowly to 
eliminate his tubercles when the disease in him has 
come to a standstill, and he shows no tendency to re- 
covery, even if he is not growing worse. The theo- 
retical object, then, aimed at by treatment is the 
elimination by the patient of most of the tubercles, or 
the permanent encapsulation of those not eliminated 
by such fibrous and calcareous material as will cause 
them to be forever outside of the body, as far as 
any relationship to the blood and lymphatic circulation 
is concerned. On the other hand, if too many 
tubercles are broken down at once, too persistently or 
too continuously, the prognosis is bad, and tuberculin 
is ordinarily not indicated. 

Our conclusions as to the subcutaneous tuberculin 
test may be as follows: 1. It is a reliable test, and is 
pathognomonic in children and young adults. In older 
adults, if the test is positive, it may be relied on as 
showing a tuberculous focus somewhere, but if the 
test is negative it is not so reliable as in children. 2. 
It should not be used carelessly, though perfectly safe 
if the beginning dose is small. 3. The tuberculin test 
is unnecessary when a localized pulmonary lesion has 
been discovered by physical examination. 4. When 
we recognize thai a patient is tuberculous or is liable 
to become so, although we find no physical lesions, the 
tuberculin test is unnecessary, as our preventive 



INTRADERMAL TUBERCULIN TESTS 179 

treatment should be the same whether reaction is posi- 
tive or negative. 5. In doubtful bone, tendon or joint 
inflammations, or when for any reason a decision must 
positively be made, the tuberculin test should be used. 

Although a reaction from tuberculin has occurred in 
cases of carcinoma, syphilis and actinomycosis, still, 
these instances are so rare that there is the probability 
that such patients had a latent tuberculosis, and hence 
the test may be considered positive. In advanced cases 
of tuberculosis, however, the test may be negative on 
account of a tolerance to the toxins already described. 

The beginning dose of "old tuberculin'' for diagnos- 
tic injection is 0.1 mg., the second dose should be 1 
mg., the third may be 3 mg. and the fourth 5 or 6 mg. 
Of course, a reaction occurring with any dilution would 
prevent the necessity or advisability of giving another 
injection. A suspected patient not reacting to 5 or 6 
mg. should be considered free from tuberculosis. 

If a physician desires, he may receive direct from 
the serum and bacterin firms the "old tuberculin'' 
properly diluted for the diagnostic test. 

Tuberculin triturates and tuberculin vaccines have 
been administered by the mouth as a possible treatment 
of tuberculosis, but such administration is as yet purely 
experimental. 

The tuberculin injection test should be used only 
with a patient who is at rest and does not have a morn- 
ing rise of temperature as shown by a series of ob- 
servations. The injection should be given at about 9 
p. m., and if there is a rise of temperature in the early 
morning, it should be considered a positive reaction, 
and if there is pain, swelling or heat discovered at an 
external suspected area, as a joint, or if there is con- 
gestion or moist rales are discovered in a suspected 
area of lung-tissue there is a "focal reaction." If 
there is a marked reaction at the region of the injec- 
tion (the "local reaction"), even if there is no general 
reaction, the patient probably has tuberculosis, and it 
may often be unnecessary to continue the injection of 
higher dilutions. 

The "intradermal" tuberculin test for the diagnosis 
of latent or concealed tuberculosis (first described by 
Mantoux and Hutinel, Bull, de I' Acad, de med., Paris, 
Oct. 27, 1908), has been recently revived and recom- 



180 MEDICATION IN TUBERCULOSIS 

mended by Jeanneret. (Rev. Med. de la Suisse ro- 
mande, 1913, No. 5, p. 373). The advantage of this 
test over the von Pirquet and the Moro skin tests is 
that a known amount of tuberculin is injected between 
the layers of the skin. The reaction is a local one, 
and there is no general disturbance like that occurring 
with the subcutaneous tuberculin test. 

Another diagnostic test is the determination of the 
presence of albumin, and its amount, in sputum. Al- 
bumin is generally present in all sputa of tuberculous 
origin, and it has been said that persistent absence of 
albumin from sputa shows that its source is non- 
tuberculous. Albumin is also present in sputa of bron- 
chitis, pneumonia and other conditions. For a discus- 
sion of this subject and a simple method of making 
the test see article by Holm and Himmelberger (Jour. 
A. M, A., Jan. 3, 1914, p. 20). 

GENERAL MEDICATION IN THE TREATMENT OF 
TUBERCULOSIS 

In the first place, drugs, as such, cannot cure, and 
are not antidotes to this disease. On the other hand, 
much can be done, with proper medication, to aid the 
physiologic processes. 

Calcium. — It has long been thought that patients 
suffering from tuberculosis have previously become 
demineralized. This means especially that they have 
lost their calcium, and perhaps phosphorus, equilib- 
rium. It is also true that tuberculous lesions heal by 
more or less calcification. Also, patients are more 
likely to have hemorrhages, if their calcium blood- 
content is diminished. Certain it is that patients, 
especially children, often improve with increased 
amounts of calcium in their food or as a medicament. 
One of the great values of a proper amount of milk 
for tuberculous patients is probably the calcium and 
phosphate content. On the other hand, many patients 
improve by the administration of a calcium salt, and 
none is better than calcium glycerophosphate, in 
0.30-gm. (5 grain) doses, three times a day, after 
meals. 

Galliot (Arch, de med. d. enf., 1913, XVI p. 289) ad- 
vises the following combination for children who arc 
suffering from tuberculosis: calcium carbonate and 



CREOSOTE IN TUBERCULOSIS 181 

calcium phosphate, each from 20 to 30 eg. (from 3 to 
5 grains) ; magnesium chlorid from 10 to 20 eg. (from 
\y 2 to 3 grains) ; magnesium oxid from 5 to 10 eg. 
(from about yi to \y 2 grains). This he administers 
two or three times a day. It has often been found 
that tuberculous patients improve under the adminis- 
tration of thymus gland. This is rich in nucleopro- 
teins, and therefore offers phosphorus in assimilable 
form, and also it seems to promote the calcium metab- 
olism. This gland is very active during childhood, 
when the greatest amount of bone growth occurs. 

Creosote. — Creosote has been long recommended 
and much used, and its action in tuberculosis has been 
lauded by able medical men. 

There is a great difference of opinion among clin- 
icians as to the value of creosote in pulmonary tuber- 
culosis. Many physicians never use it in this disease, 
and others push it to such an extent that the patient is 
practically saturated with it, and his room and almost 
the whole house reeks with the odor of creosote. It 
seems to be true that many patients have improved 
appetite under its stimulant or irritant action in the 
stomach. It may also, for a time, improve digestion, 
and the patient often adds weight. During this period 
there is frequently a lessening of the bronchitis, and 
therefore a decreased expectoration, and with this 
decrease of the secondary (streptococcic) infection, 
there is likely to be less fever and therefore less sweat- 
ing. It is so rare, however, for a patient to take creo- 
sote and not adopt the rest cure and other measures 
that go toward improving his condition, that it is not 
fair to attribute such improvement to the creosote. 
Creosote is also more or less of an intestinal antisep- 
tic, and hence bacteria-laden sputum that may be inad- 
vertently swallowed may be rendered harmless in the 
upper part of the intestine. Be that as it may, it is 
a fact that good bowel activity, an improvement in the 
intestinal digestion, and the prevention of fermentation 
or putrefaction in the intestine, by many so-called 
bowel antiseptics, will all cause an improvement in the 
tuberculous patient. 

Unfortunately, as frequent aftermaths of the good 
action of creosote the pancreas becomes overstimu- 



182 COD LIVER OIL IN TUBERCULOSIS 

lated by the drug and does not furnish its secretion 
properly; there is intestinal indigestion; the liver is 
disturbed; there are stomach indigestion and loss of 
appetite, and the patient will lose weight faster than 
he gained it under the creosote treatment. Too much 
creosote will also irritate the kidneys, and may cause 
albuminuria. In other words, it generally does not 
seem wise to recommend creosote, as such, internally 
in pulmonary tuberculosis. An an ingredient of an 
inhalant mixture it may be of value, as a positive anti- 
septic to the upper air-passages and the trachea and 
large bronchial tubes. If there is fetid, purulent ex- 
pectoration such inhalations may be of advantage. 

Guaiacol frequently in the form of a benzoate of 
guaiacol has been used for tuberculosis, but guaiacol 
has no advantage over creosote in the treatment of 
tuberculosis. The exponents of the creosote treatment 
believe that the drug should be begun in small doses 
and gradually increased to the point of the patient's 
tolerance. Tolerance means that the appetite is not 
interfered with, that there is no nausea or vomiting, 
and that the urine does not become dark and show 
albumin. 

The symptoms of creosote poisoning are similar to 
phenol poisoning. From its overaction the patient not 
only has gastritis and intestinal disturbances, but also 
dark urine, perhaps nephritis, and dizziness and sweat- 
ing. 

IchthyoL — The internal administration of ichthyol in 
tuberculosis seems to have its only advantage in acting 
as a bowel antiseptic. In this manner it may do some 
gocd, but as patients generally eructate it, it is exceed- 
ingly unpleasant treatment. Other methods of prevent- 
ing intestinal disturbances, such as ordinary laxatives, 
a cathartic perhaps once a week, the administration of 
soured milk, yeast or lactic acid bacilli, if any such 
treatments are indicated, or salol if needed, are all 
better than the ichthyol. 

Cod-Liver Oil. — This oil is a food, and as such has 
its advantages. A small dose of cod-liver oil is as 
easily taken as a large dose of some emulsion which 
contains but little of the oil. In other words, if one 
desires to give cod-liver oil, it may be given ; but, as 



ARSENIC IN TUBERCULOSIS 183 

previously stated, other oils and fats are of as much 
advantage, particularly butter, and it certainly is not 
wise to load the system with large amounts of bile- 
salts. There is no difference in the effect of Nor- 
wegian cod-liver oil and the oil prepared on our own 
shores. 

The Hypophosphites. — There is no chemical, physi- 
ologic or specific excuse for giving the hypophosphites ; 
the success of treatment of lung conditions with hypo- 
phosphites is a fallacy. It is not intended to state that 
some phosphorus and some calcium-bearing prepara- 
tions and foods containing these elements may not be 
of value, but one is not justified in expecting results 
from any hypophosphite combination of these or other 
elements. 

Arsenic. — Arsenic has been advised for years in 
many lung conditions. It has been stated that the 
arsenic eaters of France and Switzerland have been 
more or less immune from tuberculosis. It has been 
stated that patients breathe more freely and better un- 
der the influence of arsenic. However this may be, 
in the treatment of pulmonary tuberculosis the value 
of arsenic is very slight. It seems to stimulate the 
production of blood-corpuscles, both red and white, 
and in small doses it may stimulate the appetite. In 
any large doses arsenic is harmful, tending to cause 
secondary destruction of red blood-corpuscles, to irri- 
tate the kidneys, to upset the digestion, and when 
pushed, may cause multiple neuritis. In other words, 
arsenic is a poison, and should not be administered to 
a patient unless there is a tangible, positive indication. 
Arsenic has come more or less into prominence as a 
germicide since the wonderful activity shown by sal- 
varsan in the treatment of syphilis. It has long been 
known that arsenic may sometimes kill the malarial 
germ ; it seems also to have some activity in certain 
tropical germ diseases. But arsenic is such a stimu- 
lant to glandular tissue, especially to the lymph-nodes, 
that it would seem unwise, theoretically, to give a 
sufficient amount of it to cause excessive activity of 
these glands, with the probable pouring out of many 
tubercle bacilli into the lymph and blood-streams. In 



184 TUBERCULIN IN TUBERCULOSIS 

good-sized doses arsenic could probably do harm just 
as large doses of tuberculin will do harm. 

Iodin. — For many years this element in some form 
has been given frequently for various kinds of tuber- 
culosis, especially glandular tuberculosis. It was re- 
cently lauded for pulmonary tuberculosis by Bou- 
dreau. (Abstr. Jour. A. M. A., Feb. 14, 1914, p. 577.) 
He gives the French tincture (1 part of iodin to 12 
parts of 90 per cent, alcohol), and commencing with 
small doses runs it up to 100 drops a day, administered 
in various beverages. After ten years of trial, he finds 
such treatment of value not only in pulmonary tuber- 
culosis, but also in renal tuberculosis. 

Although there are no other reports concerning this 
treatment, harm has been done in pulmonary tubercu- 
losis by the administration of an iodid. It seems to be 
a stimulant to the tubercles, not unlike tuberculin, and 
may cause a lighting up of a quiescent tuberculous 
process or a serious exacerbation of a slow-going in- 
fection. The stimulant action on glands is well known, 
and tuberculous glands may be overstimulated to the 
harm of the patient. In other words, iodids should not 
be used carelessly in pulmonary and glandular tuber- 
culosis. This does not militate against the possibility 
of small, .very slowly increasing doses of iodin doing 
the same good that graded doses of tuberculin do, but 
the treatment should be most carefully watched. 

Thyroid gland substance has been given in tubercu- 
losis, but it is rarely indicated, though the thyroid is 
probably often affected in tuberculosis. 

Though the syrup of the iodid of iron has long been 
given in glandular enlargements in children, experi- 
enced observers have found no greater benefit from 
it than from some other form of iron. 

Tuberculin. — Tuberculin is not holding the position 
which was accorded to it after its recovery from the 
depression due to its early incautious use. It is not in 
itself curative, but it is, at most, a stimulant to the 
curative efforts of the organism. Some observers are 
still of the opinion that it is of value in selected cases 
of tuberculosis. The potency of tuberculin for harm 
is recognized by all. Its administration requires care- 
ful selection of the case, close observation of the 



TUBERCULOUS SYMPTOMS 185 

patient and appropriate regulation of the dose. Pa- 
tients should be treated in a hospital, or, if the remedy 
is administered to ambulant patients, a strict control 
should be exercised. Tuberculin is effective only in 
strictly localized forms of tuberculosis. Hence, the 
results are good in the forms of tuberculosis called 
surgical, such as affect the skin, bones, joints and 
lymph-nodes. Tuberculosis of the lungs, when strictly 
localized, would appear to indicate its use, but the 
different character of the tissue involved seems to 
render the results less favorable. 

Heliotherapy. — Treatment by the direct rays of the 
sun has been applied to a limited extent by Rollier of 
Leysin, especially in cases of pulmonary tuberculosis 
complicated by local tuberculosis of the bones, joints 
or glands. It is seldom used in ordinary cases of pul- 
monary tuberculosis. It should be limited to incip- 
ient cases and applied with caution, where, there is 
fever or a tendency to hemoptysis. The treatment is 
best carried out in connection with the tonic applica- 
tion of cold at high altitude. It consists in graduated 
exposure of the body to the light of the sun for in- 
creasing periods daily until the resistance developed 
permits a long stay in the open air. The treatment 
is said to be well borne by children. During the 
treatment the head should be protected and the room 
should be comfortable for the patient. 

TREATMENT OF SYMPTOMS 

Fever. — Nothing tends to diminish the temperature 
more than the rest, quiet and fresh-air treatment 
already outlined. The patient who has high fever 
should not be given too much food at any time of day, 
even if the disease is tuberculosis ; and most of what 
he does receive should be given during an afebrile 
period if possible. If he is suffering from acute tuber- 
culosis, the nutrition should be much the same as for 
any other serious fever. 

Sponging with hot water will often give these pa- 
tients comfort, and, if they have profuse sweats, it 
keeps the skin clean. The frequency of such sponging 
will, of course, depend on the height of temperature 
and its continuance. Antipyretics are rarely indicated. 



186 COUGH IN TUBERCULOSIS 

The following points should be observed in the treat- 
ment of fever: First and foremost, absolute rest in 
bed, preferably out of doors ; artificial pneumothorax in 
selected cases ; a trial with autogenous vaccines, espe- 
cially when there is copious purulent expectoration ; the 
cautious use, if at all', of tuberculin, and then only after 
other measures have failed; hydrotherapeutic mea- 
sures suited to the condition and comfort of the pa- 
tient; and ample diet, but not necessarily " forced 
feeding/' and the judicious use of medicinal antipyre- 
tics. 

Cough. — The treatment of the cough depends on 
whether it is dry or moist, and whether expectoration 
is easy or difficult. If the cough is dry and hacking, 
much of it may be prevented by the will-power of the 
patient. It should not be forgotten that many dry, 
irritating coughs are due to a lingual tonsil or throat 
irritation. Soothing, alkaline gargles, non-irritating 
inhalations of simple steam or steam medicated with 
some non-irritant drug, as a small amount of pine oil, 
will give relief. Many coughs of this kind are relieved 
by swabbing the lingual tonsil with boroglycerid. 
These dry, irritating coughs should be relieved without 
giving medicine by the stomach. 

If there is considerable bronchitis with insufficient 
expectoration, or the cough is frequent without expec- 
toration, no cough mixture is any more soothing or 
behaves better in the stomach than the following: 

Gm. or c.c. 

I£ Codeinae sulphatis 20 gr. iv 

Ammonii chloridi 5 3 iss 

Syrupi acidi citrici 25 A3 i 

Aquae q. s. ad 100 A3 iv 

M. Sig. : A teaspoonful, in plenty of water, every two, 
three or four hours, as needed. 

Heroin may be used in place of codein if desired, but 
we believe that codein is the best sedative preparation 
of the opium series to meet the indication. The action 
of all other expectorants is inferior to that of ammo- 
nium chlorid, and ammonium chlorid as prescribed 
above is not very disagreeable. The dose may be taken 
in Vichy or other sparkling water if desired. None of 
the multiple sweet, sickish, syrupy preparations offered 



PAIN IN TUBERCULOSIS 187 

by proprietary firms should be used in the bronchitis 
and catarrh of tuberculosis, or in any other kind of 
bronchitis. It is not necessary to cause nausea or 
vomiting because a patient has a cough. The success 
of some of these syrups or malt preparations in dry 
cough is due to the fact that they soothe the throat and 
lingual tonsil. Such irritation can be allayed without 
the patient swallowing a mixture. If the cough is 
loose, and if expectoration is profuse, the stimulating 
effect of ammonium chlorid and the sedative effect of 
codein are not needed, and terpin hydrate becomes the 
best drug to use, as an expectorant. To meet this 
indication of profuse bronchorrhea it will not ordi- 
narily be necessary to combine it with either codein or 
heroin. It should never be given in solutions, as not 
enough of it to be of advantage will be dissolved in 
any solution. It may be given in tablet, powder or cap- 
sule, and the usual dose is 30 eg. (5 grains), given 
with plenty of water four or five times in twenty-four 
hours. 

If there are cavities in the lungs, the patient should 
occasionally, by lying over the edge of the bed, allow 
gravity to aid him in expectorating the fluid and pus. 
Elevation of the foot of the bed is often of advantage. 
Sometimes inhalants containing creosote, oil of pine 
and perhaps benzoin are valuable. When there are 
large cavities which continue to fill up and cause septic 
fever, with the debility and loss of appetite that goes 
with it, or when there is danger of serious hemorrhage, 
it may be wise to inject air or nitrogen into the pleural 
cavity and compress the diseased lung. Such treat- 
ment should be given only in hospitals or sanatoriums, 
and then by an expert, as very unpleasant symptoms 
may occur ; the heart may be unpleasantly pressed on, 
with a serious outcome. On the other hand, the treat- 
ment is sometimes very satisfactory. 

Pain. — Pain in the chest is most frequently due to 
localized pleurisies, but it may be a neuralgia, or 
referred pain caused by disturbances of the more 
deeply seated nerves. Nothing is of more advantage 
in easing such pain than temporary strapping of the 
part of the chest affected. This is especially true of 
pain in the lower part of the thorax. Sometimes a 



188 HEMOPTYSIS IN TUBERCULOSIS 

hot-water bag will ease the pain ; rarely a sedative may 
be indicated, but generally it is not needed. Mild 
counter-irritation by a liniment or ointment is some- 
times advisable over these regions of pain ; blisters 
are rarely expedient, though the thermocautery may 
be used. Dry cupping may give relief. The pain of 
tuberculous laryngitis can be relieved by injection 
directly into the superior laryngeal nerve of alcohol or 
cocain solution, according to the technic for similar 
injections for neuralgia or local anesthesia. 

Hemoptysis. — Blood-tinged sputum or very slight 
pulmonary hemorrhages as evidenced by small clots 
or streaks of blood require no special treatment. Ex- 
pectoration of pure blood, or coughing up a little blood 
repeatedly requires attention. Such a patient should 
rest, and should undergo no exertion. The diet should 
be light, and hot soups or hot drinks should not be 
taken for a day or two, until the hemorrhage ceases. 
For this kind of bleeding little other treatment is 
necessary. If the bleeding is more severe, the patient 
should immediately be placed in a semirecumbent posi- 
tion, with loosened clothing and should be assured that 
there is no danger, as there rarely is danger from hem- 
orrhage during all the early stages of pulmonary tuber- 
culosis. In the late stages, with cavities, a large blood- 
vessel may rupture and the hemorrhage be fatal. It is 
well to have the patient lie on the side which is bleed- 
ing. This tends to prevent the blood from flowing into 
the bronchi of the other lung. 

Besides reassuring the patient, it is often well, if 
there is a troublesome, irritating cough, to administer 
a hypnotic of morphin in just sufficient dose to quiet 
the irritability of the bronchial tubes and larynx so 
that the cough will be only sufficient for expectoration. 
(It is unnecessary to give a large dose which later will 
cause prostration; hence from 1/10 to 1/8 of a grain 
will be sufficient.) 

The more rest the bleeding part has, the quicker will 
the blood coagulate in the bleeding vessels, but as above 
stated, mere capillary oozing should not be taken seri- 
ously. With a real hemorrhage from the lungs, the 
rest must be absolute; the patient should not even 
speak, at least not above a whisper. For some hours 



TREATMENT OF HEMOPTYSIS 189 

he should receive no food or drink. It is exceedingly 
doubtful if an ice-bag over the region of the bleeding 
is at all efficacious. The long-used remedy of eating 
salt may reflexly, by irritation, increase the vasomotor 
tension and thus may occasionally stop a hemorrhage, 
but most of the remedies used and said to be satisfac- 
tory in hemorrhage from the lungs are drugs that in- 
crease the blood-pressure more or less, which is unde- 
sirable. As the blood-pressure is lowered the hemor- 
rhage will generally cease, usually without medication, 
so that whatever has been given has been supposed 
to be the cause of such cessation. If the patient be- 
comes faint, blood-pressure is lowered, coagulation in 
the open vessel or vessels takes place, and the unpleas- 
ant symptoms is cured by Nature's methods ; therefore 
we should aid the natural cure of the condition by giv- 
ing the patient nitroglycerin to low the blood-pressure. 
Amyl nitrite is very frequently advised, but its action 
is so sudden, and for a few minutes so intensely dis- 
agreeable, that it is hai dly advisable to use this power- 
ful drug. Nitroglycerin on the tongue or hypoder- 
matically will act as efficiently and almost as rapidly 
without causing the* f aintness and- throbbing head that 
amyl nitrite will cause. It is a mistake to give ergot, 
caffein, suprarenal preparations, or digitalis, as these 
tend to increase the heart activity and raise the blood- 
pressure. 

If there is a tendency to repeated, more or less seri- 
ous hemorrhages, the daily administration of calcium 
in some form, either as lime-water, calcium lactate, or 
calcium glycerophosphate, and the feeding of gelatin 
are indicated. Also, if there seems to be a general ten- 
dency to the oozing of blood and to hemorrhage, injec- 
tions of aseptic horse-serum is advisable ; one or two 
subcutaneous injections will generally be sufficient. In- 
halations of steam impregnated with some astringent 
such as tannic acid may be of value, if there is oozing 
of blood from the larger bronchial tubes, but such in- 
halations are of no value in bleeding from deeper por- 
tions of the lungs, as the astringent could not reach 
the region of trouble. 

The patient should generally remain in bed for a 
week after a real hemorrhage. If the heart is im- 
paired and some dilatation exists, if the expectorated 



190 TREATMENT OF HEMOPTYSIS 

blood is venous, and there are other signs of passive 
congestion of the lungs and of cardiac weakness, digi- 
talis may be the best treatment for the condition ; but 
for ordinary hemorrhages in pulmonary tuberculosis 
it is better, as above stated, to administer nitroglycerin 
in sufficient amount distinctly to lower the blood-pres- 
sure temporarily. 

It has been repeatedly noted that constipation 
increases the tendency to hemorrhage in pulmonary 
tuberculosis, and that the higher blood-pressure caused 
by constipation is readily lowered by the administra- 
tion of even simple laxatives. Because of this, it has 
been recommended (Bly, Jour. A. M. A., Dec. 20, 
I 9 I 3> P- 2207) that when pulmonary hemorrhages 
occur, the patient should receive a dose of magnesium 
sulphate as well as nitroglycerin. Such immediate 
treatment of hemorrhage from the lungs seems hardly 
advisable. It might cause vomiting, and the mere in- 
creased exertion caused by bowel movements at this 
time, might cause more bleeding. The fact remains, 
however, that in pulmonary tuberculosis the patient 
should not be allowed to become very constipated. 

If the hemoptysis occurs late in the disease and is 
dangerous in amount, the patient may quickly suc- 
cumb, whatever the treatment adopted. The most 
efficient treatment of this serious condition is to place 
elastic bandages high up on the legs, or even all the 
extremities, to shut off their blood from the general 
circulation. It would be inadvisable, even if the hem- 
orrhage was severe, to transfuse immediately, as any- 
thing that raises the blood-pressure will be likely to 
cause a return of the hemorrhage from the open ves- 
sel. Later, after the hemorrhage has ceased and suf- 
ficient time for thorough coagulation has passed, the 
extremities, one at a time, may be released and the 
blood contained in them allowed to return to the 
general circulation. 

Continued bleeding from the lungs (especially when 
cavities exist and a serious hemorrhage has taken 
place, or seems likely to occur) is one of the most im- 
portant indications for the use of lung compression. 
Other indications, as previously suggested, are the 
presence of pus in a cavity in the lungs, and bron- 



NIGHT SWEATS IN TUBERCULOSIS 191 

chiectasis. For either of these conditions lung com- 
pression is becoming more and more popular with 
specialists in tuberculosis. It is also wise, perhaps, to 
compress a lung when, in spite of some weeks of 
proper treatment, the disease continues to spread in it, 
the other lung being normal. 

The gases that may be injected into the pleural 
cavity are nitrogen, oxygen and nitrogen, oxygen and 
air, or air and nitrogen. If only temporary compres- 
sion is desirable, air, or a gas rich in oxygen seems 
indicated, as its absorption is more rapid. If a pro- 
longed compression is desired, nitrogen should, per- 
haps, be used, as it is less readily absorbed, and 
therefore the compression is longer continued. A 
mixture of air and nitrogen is perhaps a good com- 
bination when a brief compression is desired, and 
being more rapidly absorbed than nitrogen, will allow 
a decision as to the ability of the patient to stand this 
compression before using the longer compression by 
nitrogen. It has also been urged that air compression 
is safer than by nitrogen from the fact that if gas 
bubbles enter the circulation, the air bubble is more 
quickly absorbed than the nitrogen bubble. Good 
technic with proper instruments, however, should 
preclude such an accident. 

If compression is once done and its continuance is 
desired, more gas should be injected before all of that 
previously injected is absorbed, as after an injection 
has once been made, and the pleural surfaces have 
come together, they become more or less adherent and 
it is difficult to inject the gas again into this pleural 
cavity. 

Night-Sweats. — This debilitating symptom is very 
characteristic of tuberculosis, and may occur even 
without much afternoon or evening fever; generally, 
however, it follows such increase of temperature. 
Therefore, the rest and fresh-air treatment that pre- 
vents a rise in temperature will also ameliorate or pre- 
vent the night-sweats. If, however, typical cold night- 
sweats occur, nothing in the way of medication more 
successfully prevents them than atropin, 1/200 to 
1/100 of a grain, given dry on the tongue at bedtime. 
The hydrotherapeutic measures already advised, that 



192 DYSPNEA IN TUBERCULOSIS 

is, the warm water, and later cold water morning 
spongings are of value as preventives. If the patient 
is at rest and is getting no exercise, good massage 
followed by an alcohol rub is an excellent method of 
stimulating a more healthy circulation in the skin and 
muscles, and diminishing the tendency to profuse 
perspiration. The avoidance of constipation, a healthy 
circulation and good activity of the kidneys, all pre- 
vent night-sweats and the accumulation of toxins in 
the blood. If there is much circulatory weakness; 
several doses of strychnin sulphate a day, or digitalis, 
may also prevent night-sweats. 

Diarrhea. — Simple diarrhea occurring in tuberculosis 
patients generally means either that the patient be- 
comes chilled, or that the diet is incorrect. Correction 
of these conditions will soon stop such diarrhea. 
Tuberculous diarrhea, i. e., a diarrhea due to tuber- 
culous disease of the intestine is a serious complication 
not only of pulmonary tuberculosis, but also of any 
other form. It often occurs in the last stage of the dis- 
ease. Rest in bed and a carefully selected diet should 
be the treatment. Whether the diet consists of milk 
alone, or of a little meat and eggs with milk, should 
depend on the patient. Generally, vegetables, fruit 
and even much cereal should be temporarily withheld. 

Bismuth subcarbonate may stop the diarrhea, but 
bismuth should not be long continued. Lime-water 
may be of benefit. If the kidneys are normal and 
there is no albuminuria, phenyl salicylate (salol) is 
good treatment. At times, one of the creosote com- 
binations in valuable. The administration of opium in 
some form may be necessary before diarrhea can be 
checked, and in the last stages of tuberculosis diarrhea 
may not be prevented. Colon washing with warm 
physiologic saline solutions is sometimes markedly 
sedative and of value. The bowels should always be 
kept especially warm, and the patient with diarrhea 
should not be subjected to intense cold. 

Dyspnea. — If the patient is in the last stages of 
pulmonary tuberculosis and must soon die, there is no 
excuse for not preventing the air-hunger, and morphin 
administered in properly selected, small doses, will 
often relieve the dyspnea. In the very last stages, if 



LARYNGEAL TUBERCULOSIS 193 

the patient cannot be out of doors to get an increased 
amount of oxygen, he may be given oxygen inhala- 
tions. But oxygen inhalations as a curative procedure 
are useless and may even do harm. 

The Pneumonic Type of Pulmonary Tuberculosis. — ■ 
Such a condition is likely to occur as a part of acute 
miliary tuberculosis, but it may develop in a lung as an 
acute exacerbation of a chronic tuberculosis. The 
disturbance may be ushered in with a chill, high, irreg- 
ular temperature, frequent, short cough, considerable 
dyspnea, at first without physical signs of gross con- 
solidation, but later showing in a part of a lobe, or 
even the whole lobe, the usual pneumonic signs, even 
with rusty sputum. The rusty expectoration soon 
disappears, however, and yellowish, greenish sputum, 
perhaps blood-streaked and loaded with tubercle ba- 
cilli, occurs. The prognosis is very serious, but the 
acute exacerbation may cease. The treatment is not 
dissimilar from that of an ordinary pneumonia. 

Laryngeal Tuberculosis. — The prognosis of this con- 
dition has, up to recent years, been considered very 
bad indeed, but with more skillful treatment by throat 
specialists, with the added rest-cure and with tuber- 
culin treatment, many such cases are aborted and the 
lives of the patients saved. The instances of tuber- 
culosis of the larynx are rare in which, preceding or 
subsequent to the beginning of the laryngeal disease, 
some portion of the lungs will not be found affected. 

The exact local treatment of a tuberculous larynx 
depends, of course, on the location of the ulcer or 
ulcers. If they are so situated that swallowing is very 
painful, anesthetizing sedatives must be used. Various 
preparations of silver, lactic acid and menthol are used 
by different clinicians to aid in healing the ulcers, but 
the tuberculin treatment, properly used, is probably 
always advisable. The injection of alcohol or of 
cocain solution along the course of the superior laryn- 
geal nerve may afford marked relief in this disease. 

Tuberculous Peritonitis. — This condition uncompli- 
cated with tuberculosis elsewhere must, of course, be 
differentiated from many abdominal conditions. If 
there is fluid, other causes of ascites, as inflammation 
of the liver, serious cardiac insufficiency and ovarian 



194 TUBERCULOUS PERITONITIS 

cyst's must be excluded. Tuberculous peritonitis may 
appear in several forms : the miliary form which 
causes ascites, the fibrocaseous, the fibro-adhesive and 
that which causes tumor-masses. The range of tem- 
perature (although in chronic tuberculous peritonitis 
there may be no increase of temperature, and it may 
even be subnormal), the localized tumor-masses and 
fluid confined to one portion of the abdominal cavity 
by adhesions, will aid in the diagnosis. In tuberculous 
peritonitis there may be more fluid on the left side of 
the abdomen than on the right, as the diseased mesen- 
tery retracts and draws the bowel to the right. As 
frequently tuberculosis is not present in other organs, 
the diagnosis is often difficult, and a tuberculin test is 
indicated. The fluid in the abdomen in tuberculous 
peritonitis does not contain pus, unless there is a mixed 
infection, as the tubercle bacillus does not produce pus. 
The drawn serum very frequently does not show tu- 
bercle bacilli, but a guinea-pig inoculated with the 
serum will, in due time, develop tuberculosis, if that 
is the infection from which the patient is suffering. 
If the exudate found on laparotomy or withdrawn for 
examination is bloody, it shows the disease is active. 
Tuberculous peritonitis may originate from infected 
mesenteric glands. Much false membrane is formed, 
which causes many adhesions of the intestines. 

A patient may apparently be very well and still 
suffer from tuberculous peritonitis, and the prognosis 
is rather favorable if such a patient is operated on. It 
is not advisable to operate for tuberculous peritonitis 
if tuberculous infiltration is already in the lungs. At 
times, withdrawal of fluid from the abdomen by aspira- 
tion, tonic treatment, rest and the exposure of the 
abdomen to the rays of the sun will cause a cure. 
Many sanatoriums are installing the necessary equip- 
ment for giving heliotherapy, cr sun baths. The direct 
rays of the sun are thrown on the chest or abdomen. 
The electrochemical action of the Roentgen ray has 
also been tried, but its value lias not been well proved. 

If the ascites tends to recur, or remains, laparotomy 
should be done, and sunlight let into the abdomen. 
Laparotomy may cure tuberculous peritonitis when 
there are simply tuberculous masses or tumors, but no 
fluid in the abdomen. It has been thought that small 



TUBERCULOUS GLANDS 195 

doses of mercury administered for. a long period, 
especially in the form of corrosive sublimate, was of 
advantage in tuberculous peritonitis. 

The results of operation may be summed up about 
as follows : There is slight danger from the operation 
itself. Temporary improvement may almost always 
be expected. Fatal cases usually terminate in a few 
months after the operation; while not far from one- 
third of all cases seem to recover in about one to two 
years after the operation. Antiseptic injections or 
continuous drainage after operation are not indicated 
and are useless. 

Tuberculosis of the Genito-Urinary Tract. — Tuber- 
culosis of the bladder and prostrate is rarely primary, 
and often has gonorrhea as an antecedent. Tuber- 
culosis of the testicle is by no means infrequent. 
Removal of the testicle is of course advisable, and 
operative interference in the bladder and prostrate may 
be indicated. A tuberculous kidney should be removed 
as soon as it is diagosed provided the other kidney is 
normal. The general treatment is the same as in all 
tuberculosis. 

Tuberculosis of the Cervical Glands. — Although this 
subject has already been quite largely discussed, it 
should be urged that while surgical removal is neces- 
sary and very frequently indicated, every gland that 
is needlessly removed weakens by just so much the 
ability of the system to protect itself against all infec- 
tions. Roentgen-ray treatment, while lauded by some 
men, seems unsatisfactory to many clinicians. While 
infected or broken-down glands are being removed, 
the dissection should be very carefully done, lest the 
surrounding parts be infected with liberated germs, or 
if not locally infected, lest the bacilli be absorbed into 
the lymph circulation and cause general infection. 

While a gland should not be removed merely 
because it is enlarged, at the same time it is a serious 
mistake to allow enlarged glands to cause such inflam- 
mation of the surrounding tissues as to render it neces- 
sary to remove parts of muscles, to say nothing of 
the danger of such chronic inflammation necessitating, 
during operation, injury to important blood-vessels 
and nerves. Glands should be removed before they 
cause injury to the patient or the surrounding tissues. 



196 BONE AND JOINT TUBERCULOSIS 

The tuberculin treatment of tuberculosis of the 
glands, especially in children, is now much in vogue, 
and if the tuberculin is used in carefully graded doses 
the results seem to be satisfactory. Caseated glands 
should be eradicated or curetted, however, as the 
tuberculin treatment will not cause resorption. Also, 
the exact value of the tuberculin treatment for tuber- 
culous glands cannot be determined, as fresh air, good 
food, iron tonics, and medical supervision are active 
aids in the cure of this condition. Too large doses of 
tuberculin may overstimulate the diseased glands and 
cause general infection. Also, one does not know how 
many concealed diseased bronchial glands will be stim- 
ulated by the tuberculin injections; hence a very care- 
ful study of focal reaction should be made through- 
out the treatment. Bier's hyperemic treatment is 
probably inexcusable. 

Bone and Joint Tuberculosis. — In tuberculosis of 
these parts of the body, according to Fiske, there may 
be a slight leukocytosis of not far from 12,000, while 
in osteomyelitis the leukocytosis is generally not far 
from 16,000. Children who have bone tuberculosis 
frequently do well at sanatoriums or in hospitals espe- 
cially arranged for their out-door or veranda treat- 
ment. They do especially well at the seashore, and 
direct sunshine makes a valuable addition to the treat- 
ment of this kind of tuberculosis. Tuberculosis of the 
glands and bone and joint tuberculosis do especially 
well under treatment by sun baths, both general and 
local, in combination with the invigorating effects of 
cold at moderately high altitudes. Rollier of Leysin 
and other practitioners at sanatoria in the Alps and 
at a few places in the United States have secured 
particularly good results by this form of treatment. 
Such treatment can be given at home by the institution 
of simple arrangements at first in the patient's room, 
later on a veranda and finally when the surgical con- 
dition will permit, by free movement in the open air. 

Tuberculous Meningitis, — Tuberculous meningitis, 
sometimes called basilar meningitis, or water on the 
brain, may be a part of acute miliary tuberculosis, but 
it frequently occurs in children without other apparent 
tuberculosis, though careful necropsies in children 



ACUTE MILIARY TUBERCULOSIS 197 

dying of this disease may show signs of tuberculosis 
in the lungs. Tuberculous meningitis is generally a dis- 
ease of childhood, occurring most frequently between 
the ages of 2 and 5. Measles and whooping-cough 
seem to be predisposing causes, simply because they 
irritate already infected glands, and these glands then 
pour out tubercle bacilli which causes a local acute 
infection. Tuberculous meningitis may also follow, in 
rare instances, a bone tuberculosis. 

Enough cases are now on record to show that recov- 
ery from tuberculous meningitis is possible, so that the 
prognosis is not absolutely hopeless, although very 
dire. The little patient should be kept very quiet, and 
in a darkened room, and lumbar puncture should be 
done for relief of any symptoms of pressure, as well 
as for diagnostic purposes. If the child is suffering 
pain, codein or some form of opium should be admin- 
istered, on doses found sufficient for the individual, but 
not large enough nor so frequently repeated as to 
produce coma ; that is, if coma occurs it should be 
known that it is caused by the disease and not by the 
drug. The little patient should not be compelled to 
suffer severe pain. If food is refused, forced feeding 
may be advisable, but if the child is thirsty he will 
generally drink milk. The value of hexamethylenamin 
is still doubtful. It has for the last few years been 
thought to be a most valuable treatment in all infec- 
tions of the meninges or adjacent parts, as the middle 
ear, etc., and in colds and sinus disturbances. Late 
investigations, however, show that this drug does not 
give up its formaldehyd radical except in such acid 
mediums as are found in the bladder. The drug in 
ordinary doses, with the kidneys intact, is harmless, 
however, and should be given until it is certain that it 
is of no value. 

Acute Miliary Tuberculosis. — This occurs in several 
forms ; one in which all the organs of the body are 
attacked, others in which only certain organs are dis- 
eased. In another form the tubercles may be larger 
and show degeneration. The disease is always serious, 
generally fatal, and clinically occurs as the meningeal 
form just described or as a general acute bronchopneu- 
monia of both lungs, or as the typhoid type. In the 



198 PROGNOSIS IN TUBERCULOSIS 

lung form the sputum is loaded with tubercle bacilli 
and the diagnosis is readily made. In the typhoid form 
there may be no cough, and no real lung signs, 
although lesions may be found in the lungs on nec- 
ropsy. It may be difficult at first to distinguish this 
form from typhoid fever, but the temperature is likely 
to be very high in the evening with considerable of a 
drop in the morning, and profuse sweatings. Such 
morning remissions occur early in the disease as dis- 
tinguished from typhoid fever. The pain and tender- 
ness in the abdomen, and the joint and cerebral symp- 
toms, will soon make the diagnosis positive. Diarrhea 
generally does not occur with acute miliary tuber- 
culosis; in fact, the patient is generally constipated — 
another symptom different from most cases of typhoid 
fever. 

The treatment is similar to that of any acute infec- 
tion with the exception that great care should be exer- 
cised to sterilize every excretion from the body. 

Tuberculous Rheumatism. — Poncet and others have 
described cases of pain and swelling of the joints due 
either to the circulation of tuberculous toxins in the 
blood or to the presence of a small number of tubercle 
bacilli in the affected joints. It is probable that a con- 
siderable number of cases of ordinary rheumatism are 
due to tuberculosis. An almost positive sign of such 
cases is the occurrence of focal reactions, (pain and 
swelling) in the joints after injection of old tuberculin 
subcutaneously. 

PROGNOSIS 

In the first place, as to the probability of cure of 
tuberculosis, it should be remembered that statistics of 
necropsies show that from 30 to 35 per cent, of 
patients who have died from causes other than tuber- 
culosis show evidence of that disease, either healed or 
latent. In general, the prognosis of pulmonary tuber- 
culosis is modified by the family history, by the causes 
which have allowed the tuberculosis to develop, by the 
whole general condition of the patient, and by the 
amount of lung-tissue involved. A tuberculous process 
that begins in the lower part of the lung, following a 
pneumonia, gives a bad prognosis. A generally debili- 
tated and anemic condition will necessarily slow or 



EARLY PROGNOSIS IN TUBERCULOSIS 199 

preclude a cure. An associated laryngeal or intestinal 
complication makes the prognosis very serious. 

When a patient is first seen, the prognosis should be 
guarded, as it is only after weeks or months that the 
decision can be made as to how much this patient may 
improve, for even a person who looks otherwise well, 
except for the fact that tuberculosis is discovered, may 
develop an acute form of the disease. The physician 
should individualize the patient, not only as to his sur- 
roundings and his occupation, but also as to his men- 
tality. His disposition should be studied. It is a 
mistake to send a patient to a sanatorium who will be 
restless under sanatorium restrictions, or who will be 
so seriously homesick as to lose his appetite, or who 
will not at all obey instructions. Therefore, the men- 
tality, the individuality and the willingness to cooper- 
ate of the patient is of great importance in the prog- 
nosis. On the other hand, even a child from 1 to 2 
years of age who becomes tuberculous need not neces- 
sarily die of the disease. It is possible for children 
seriously affected with more or less general tuberculo- 
sis to recover. It is stated that 80 per cent, of children 
infected before the age of one year will die, while not 
more than 20 per cent, of those infected after 2 years 
of age will die. 

It is a question whether asthma, which was long 
supposed to protect against tuberculosis, really does 
so. Certainly an asthmatic patient could have tuber- 
culosis. It seems to be a fact that persons who suffer 
from heart-disease, especially if there is sufficient loss 
of compensation to cause more or less dyspnea and 
pulmonary passive congestion, do not have tubercu- 
losis so readily. This subaeration may interfere with 
the growth of tubercle bacilli. 

Tuberculosis of the cervical lymph-nodes may be 
due to an auto-infection. In other words, bacilli may 
be contained in the patient's own sputum, infect the 
tonsils and be there carried to the cervical glands. 

A more or less continuously rapid pulse gives a bad 
prognosis. A temperature that is not greatly lowered 
by rest gives a bad prognosis. Of course, the case is 
serious as long as there is a morning fever. A patient 
whose temperature is normal or subnormal in the 
morning, even if there is considerable rise in the after- 



200 ARRESTED TUBERCULOSIS 

noon and evening, may not only improve, but may 
recover. Any sexual excess, and even any sexual act 
during tuberculosis will aggravate the condition. A 
slight gain in weight, while desired and looked for, 
and generally an indication that the patient is improv- 
ing, is not necessarily a positive indication that the 
prognosis is absolutely good, as many instances occur 
in which the patient gains weight for a time, under 
proper treatment, but the disease progresses. There- 
fore, a slight but steady gain in weight should be con- 
sidered satisfactory, but should not cause too favorable 
an opinion of the outcome to be given. 

It is considered a good prognosis when the lympho- 
cytes in the blood are increased in number, showing 
that the nutrition is improving. It has also been con- 
sidered that a normal number of eosinophils gives a 
good prognosis, while an absence of eosinophils gives a 
bad prognosis. Whatever the condition, however, it 
should constantly be borne in mind that pulmonary 
tuberculosis is curable in the first and second stages, 
and a cure may even take place in the third stage, or 
when there are cavities. 

Reyher (Monatschr. f. Kinderh., 1913, XII, p. 82) 
has found a coincidence between orthostatic albumin- 
uria and tuberculosis. He investigated twenty patients 
suffering from this condition of orthostatic albumin- 
uria, and found a hereditary taint, enlarged cervical 
glands, enlarged bronchial glands and reaction to the 
tuberculin test in all of them. 

Pregnancy in a tuberculous patient makes the prog- 
nosis bad, and should call for a consultation to decide 
as to whether or not abortion should be produced. 

ARRESTED TUBERCULOSIS 

A patient who has even a temporary return to health 
must generally go to work, and the question of vital 
importance is, What shall the work be? There is 
no light outdoor work suitable for such recovered 
patients; hence, unless the occupation is one that is a 
menace to his health, a patient should return to his 
previous work. The education received during his 
cure should have taught him how to live to keep his 



PELLAGRA 201 

health. The next important rule for him to follow 
is to return to his physician for observation and ad- 
vice at shorter or longer intervals, depending on his 
general condition. 

PELLAGRA 

The Thompson-McFadden Pellagra Commission in 
briefly summarizing its first progress report said : 
"The supposition that the ingestion of good or spoiled 
maize is the essential cause of pellagra is not sup- 
ported by our study. Pellagra is in all probability a 
specific infectious disease communicable from person 
to person by means at present unknown. We have 
discovered no evidence incriminating flies of the genus 
Simulium in the causation of pellagra, except their 
universal distribution throughout the area studied. If 
it is distributed by a blood-sucking insect, Stomoxys 
calcitrans would appear to be the most probable car- 
rier. We are inclined to regard intimate association 
in the household and the contamination of food with 
the excretions of pellagrins as possible modes of dis- 
tribution of the disease. No specific cause of pellagra 
has been recognized." A second progress report 
{Jour. A. M. A., Sept. 26, 1914) says: "Children 
under the age of 2, adolescents for about five years 
following puberty and adult males in the active period 
of life are at least frequently affected by pellagra. 
On the other hand, women from 20 to 44 years of age, 
old persons of both sexes and children from 2 to 10 
years of age are most frequently affected. No definite 
connection between occupation and the occurrence of 
pellagra has been found, although the high pellagra 
morbidity in the women and children points to the 
home as the place in which the disease is usually con- 
tracted. Evidence of close association with a pre- 
existing case was disclosed in more than 80 per cent, 
of cases. 

A house-to-house canvass of the homes of over 
5,000 people living in six endemic foci of pellagra 
failed to disclose any definite relation of the dis- 
ease to any element. In six villages studied new 
cases of pellagra originated almost exclusively in a 
house in which a preexisting pellagrin was living, or 
next door to such a house, suggesting that the disease 



202 TREATMENT OF PELLAGRA 

has spread most rapidly in districts where insanitary 
methods of sewage disposal have been in use. Addi- 
tional evidence was obtained to support the conclusion 
that flies of the genus Simulium have nothing to do 
with pellagra. Animal inoculations and the experi- 
mental study of intestinal bacteria yielded no conclu- 
sive results. The studies of the blood showed a 
lymphocytosis in most cases, but have not disclosed any 
constant abnormality characteristic of pellagra. There 
was no evidence of inheritance of pellagra. The 
immediate results of hygienic and dietetic treatment in 
adults have been good, but after returning to. former 
conditions of environment, most of the cases have 
recurred. In children, prognosis is very much more 
favorable. ,, 

In brief, these conclusions call attention to the pres- 
ent status of knowledge regarding the etiology and 
prevention of pellagra. They show the existence of 
two camps, one believing in the infectious nature of 
this disease, the other inclined to the belief that it is 
essentially a disturbance of metabolism. 

Alessandrini and Scala have advanced the view that 
drinking water, because of the presence of silica in col- 
loidal solution, may be of consequence in the causa- 
tion of pellagra. 

Goldberger (U. S. Pub. Health Reports, Sept. 12, 
1914) summarizes the work of the United States Pub- 
lic Health Service on the study of pellagra and 
advances some most suggestive facts which point 
strongly to the belief that pellagra is essentially a dis- 
ease of dietary origin, brought about in some such 
way as, for example, by the absence of essential 
vitamins from the diet, or, as has been suggested by 
Meyers and Voegtlin {Pub. Health Rep., June 19, 
1914) on the presence in vegetable foods of excessive 
amounts of a substance such as soluble aluminum 
salts. 

An Illinois Pellagra Commission (Arch. Liter. Med., 
August, 1912) reported results which incline rather 
to the infectious causation of the disease. 

TREATMENT OF PELLAGRA 

According to Voegtlin (Jour. A. M. A., Sept. 26, 
1914) all physicians who have had much experience 



TREATMENT OF PELLAGRA 203 

in the treatment of pellagra agree on one point; 
namely, that in the milder cases the symptoms will 
almost always disappear in a relatively short time if 
the patients are kept in a hospital, at rest, on a lib- 
eral mixed diet, with plenty of fresh meat. He has 
found drugs of little value, but calls attention to the 
use of arsenic which has been highly recommended 
by Lombroso. He warns especially against placing 
the slightest faith in proprietary pellagra "cures." 

Niles (Jour. A. M. A. } Jan. 24, 1914, p. 285) gives 
an optimistic survey of the status of pellagra treat- 
ment. His observations cover over six hundred cases. 
In the hygiene of the disease two measures are of 
greatest importance, the forbidding of alcoholic bev- 
erages, which he has found are extremely detrimental, 
and the avoidance of direct sunlight except in spring 
and summer. There seems to be no doubt, as Voegt- 
lin also remarks, that the skin of the pellagrin is 
hypersensitive to sunlight. 

Diet. — Corn bread and corn-products are prohibited 
until the "zeistic" theory is disproved, as a precau- 
tionary measure. The diarrhea does not indicate a 
limitation in the dietary regimen. Tender steak, roast 
beef or mutton may be allowed once or twice daily, 
if the mouth is too sore to allow chewing, beef or white 
meats, either scraped or ground, may be substituted. 
Eggs are generally permissible, though it is well to 
use only the whites if flatulence exists. Sweet milk 
is valuable when it agrees with the patient. Fresh or 
artificially soured buttermilk is nearly always suitable. 
Niles believes that during the whole course of pellagra 
the individual should be nourished to the limit of 
assimilation. Goldberger advises that beans and peas 
may be eaten if fresh meat cannot be secured. In the 
winter the dried, not the canned, variety of the veg- 
etables should be as large a part of the diet as they 
form in summer. 

Medical Treatment. — Niles gives hypodermically 16 
minims of iron arsenite solution and ^4 grain of 
sodium cacodylate in solution. These may be obtained 
in sterile ampules. The two drugs are given on alter- 
nate days, one being given every other day for about 
two weeks. After that the dose is given every two 



204 TREATMENT OF PELLAGRA 

days, still alternating the ampules. After acute symp- 
toms have subsided the time between alternate injec- 
tions is increased to three days and this is continued 
over several months. 

By mouth he gives saturated solution of potassium 
iodid and Fowler's solution, in the proportion of five 
of the first to three of the second. Beginning with 5 
drops in water, three times daily after meals, the 
dose should be increased one drop each day, until 
symptoms of arsenical saturation are manifested. This 
generally appears when 20 or 30 drops are being taken. 
When there is puffiness about the eyes on arising, stop 
the drops for two days, beginning again at the min- 
imum dose of 5 drops, and increasing as before. This 
procedure is continued until the eruption and sore 
mouth are abated, and then continue in 8- or 10-drop 
doses for several months. Should there arise a gastric 
or intestinal intolerance, which is an occasional compli- 
cation, it may be necessary to reduce the proportion of 
Fowler's solution to one or two in eight parts, instead 
of three. 

For the frequent diarrhea satisfaction is obtained 
from bismuth betanaphthol and resorcin, with milk of 
bismuth as a vehicle. This failing, 15 grains of tanni- 
gen after each loose action, or, as a last resort, pow- 
dered opium may be given. 

For the infrequent constipation, either castor oil, 
liquid petrolatum, phenolphthalein or enemas will 
serve, drastic cathartics being inadmissible. 

For the sore mouth, a solution of thymol, 1 grain 
to the ounce of water, a little alcohol being used as a 
solvent, will generally prove sufficient; or a solution of 
sodium borate and glycerin. For the stomatitis and 
glossitis, a daily application of a silver nitrate solu- 
tion (20 grains to the ounce of water) is in most 
instances efficacious. 

Stomach lavage is unnecessary, except in rare 
instances, when a great excess of sticky mucus con- 
stantly arises. 

The simple erythematous rashes or even the slouch- 
ing conditions in the hands and feet may be benefited 
or cured by the bland ointments, such as zinc oxid, 
or a 5 per cent, boric acid. Raw or weeping surfaces 






HYDROTHERAPY IN PELLAGRA 205 

are soothed by a lotion of calamine and zinc oxid 
in lime-water, to which may be added a little rose- 
water or other pleasant adjuvant. 

For the intense burning in the hands and feet, so 
often and bitterly complained of, either ice-cold com- 
presses of a mild solution of mercuric chlorid, phenol 
(carbolic acid), 60 grains to the pint, applied at fre- 
quent intervals to the unbroken skin, or baths of hot 
mustard water are indicated. Two- or 3-grain doses 
of acetanilid, or 5-grain doses of acetylsalicylic acid, 
when the heart action is fairly good, will greatly relieve 
the neuralgic pains. 

After the erythema has subsided, leaving a rough 
and harsh surface, alcohol rubs at frequent intervals 
will facilitate the disappearance of this horny layer. 

Should mental symptoms predominate, deepening 
into melancholia, or lapsing into dementia, the patients 
should be placed in an institution for the mentally sick, 
as it is unwise, because of their varying or suicidal 
moods, to attempt their care at home. 

Hydrotherapy has in many instances proved so ben- 
eficial in pellagra that some form of it, such as hot or 
cold baths, simple or medicated douching, packs, 
moist or dry rubs, accompanied by special massage, 
may be employed in nearly every case. Increased oxi- 
dation of the tissues, more rapid elimination, greater 
metabolic activity, sharpened appetite, improved diges- 
tion and assimilation, and a noticeable tonic effect on 
the whole living organism follow their use. 



-* 



DISEASES OF THE RESPIRATORY 
TRACT 



Colds far surpass in frequency any other disease 
condition. There is no immunity acquired by surviv- 
ing a coryza, a pharyngitis or a bronchitis ; in fact, 
ordinarily, the person is at least temporarily more sus- 
ceptible to taking or developing a fresh cold. This 
may not be quite true of an influenza or grip cold, 
because many persons have a real or pseudogrip attack 
early in the fall or winter and are then more or less 
immune from acute attacks during the rest of that 
season ; but there seems to be no doubt that the influ- 
enza bacillus leaves a patient temporarily, at least, more 
susceptible to other more dangerous germs, as the 
pneumococcus or tubercle bacillus. Consequently, be- 
sides the immediate debility that an acute cold causes, 
the possibility of opening the way for the entrance of 
more serious disease should cause every cold to be 
considered seriously and treated energetically. 

While it is asserted by some that acute colds are 
always due to germs of some kind, it is conceivable 
that a too dry atmosphere, which is the condition in 
so many houses today, may so irritate or congest the 
nostrils as to allow the least irritant to cause at first a 
simple inflammation of the mucous membrane, which 
congested area may later pick up and harbor, or cease 
to kill, germs. It seems to be an established fact that 
good outdoor air does not predispose to colds as much 
as indoor air, and it is a fact that persons whose occu- 
pation is indoors are more liable to have colds than 
those whose occupation is outdoors. Whether or not 
every cold is due to contagium or to a germ, chilling, 
whether indoors or outdoors, certainly predisposes to 
colds. It is quite probable that chilling of the surface 
of the body congests the inner organs and possibly the 
mucous membranes of the air passages. If the mucous 
membrane of the nose is congested, it more readily 
becomes inflamed by irritation or by germs. 



ACUTE CORYZA 

This acute nasal catarrh, often called a "cold in the 
head," is of frequent occurrence in some regions, espe- 
cially near the seacoast, and occurs repeatedly in cer- 
tain persons who seem to have a susceptibility to 
inflammation in the nose. Some persons cannot be 
exposed to a single draft on any part of the body 
without an acute coryza starting. It is supposable, 
however, that while most acute nasal catarrhs are due 
to infectious germs, more or less chronically hyper- 
trophied mucous membrane and more or less sluggish 
circulation in this membrane may allow simple non-in- 
fectious catarrhs to occur when irritation of any kind 
is applied. Other persons who do not have this sus- 
ceptibility may become chilled, may be subjected to 
violent cold, damp winds, and may even get wet and 
still never develop a nasal catarrh. Just as large 
tonsils more readily catch germs and become diseased, 
or more readily harbor germs and have recurrent in- 
flammations, so hypertrophied mucous membrane of 
the nostrils becomes susceptible to reinfection or to 
reirritation. Frequent acute colds, more or less con- 
stant subacute inflammations, or chronic catarrh may 
result from such a condition. 

Some persons are susceptible to certain kinds of irri- 
tants, whether it be a particular kind of dust, a par- 
ticular kind of pollen from plants, or the emanations 
or odors from stables, horses, etc. If this susceptibil- 
ity is in excess, or occurs at certain times of the year, 
the patient becomes a so-called hay-fever or rose- 
fever sufferer, and then shows symptoms of anaphy- 
laxis. 

TREATMENT 

The preventive measures have already been referred 
to and described. They consist of proper bathing to 
keep the skin in good condition ; proper clothing, 
depending on the region, season and exposure ; proper 
heating and ventilation of living rooms, bedrooms and 
buildings in which persons are employed, and in the 
case of the child, proper heating and ventilation of 
the schoolrooms. Too severe exposure of young chil- 
dren and babies to dampness and winds is inexcusable 
and does not increase their resistance against catching 



208 ACUTE CORYZA 

cold, and often precipitates more serious conditions. 
Any person who has a tendency to nasal or pharyngeal 
colds should not suffer undue exposure at night. Too 
many windows being open may cause too much direct 
draft over the face. Fresh air sleeping should be gov- 
erned by common sense. Cold daily sponging of the 
child's face, neck and chest, followed by quick friction, 
is a splendid means of decreasing the likelihood of 
catching cold or becoming chilled. Older persons may 
take cold showers or cold plunges in the morning, if 
it is advisable in individual cases. 

Children especially should not be subjected to 
unnecessary infection by being taken into crowded 
cars, stores or into various assemblages, where it is 
impracticable to avoid close contact with coughing or 
sneezing persons who do not properly protect the sur- 
rounding atmosphere by using handkerchiefs. 

As so many times urged, a child or adult who has 
repeated colds should be examined and properly 
treated medically or surgically by a nose and throat 
specialist. The family should also be taught that the 
exchange of handkerchiefs and the use of the same 
towels when one member of the family has a cold or 
sore throat is inexcusable. Direct contagion by this 
method is probably very frequent. During all colds 
the nasal and throat secretions or excretions should be 
received into paper handkerchiefs, or pieces of cheese- 
cloth, and either immediately burned or deposited in 
a paper bag for burning later. If handkerchiefs are 
used, they should be washed separately and soon. 

A too dry indoor atmosphere can harm the mucous 
membranes of the upper air passages as it leaves the 
membranes unprotected, and the first irritant that at- 
tacks them may cause an inflammation. 

Acute coryza having begun, an attempt should be 
made to abort it. There are various methods of reliev- 
ing internal congestions, and the general principles are 
the same in all cases, wherever the localized inflamma- 
tion may be. These general methods are some means 
to reduce an increased temperature, some means of 
bringing the blood to the surface of the body and 
increase perspiration, some means to produce free 
catharsis and thus to deplete the blood-vessels and 
lower the blood-pressure to relieve indirectly the ten- 



DRUGS IN CORYZA 209 

sion in the region of congestion, and some means to 
prevent the development of the second stage, or stage 
of secretion, if possible. Methods used to meet one 
of these indications will many times meet one or more 
of the others ; hence the treatment is often very simple. 
If the patient is first seen in the morning, or before 
the middle of the afternoon, the best treatment is a 
saline purge of some description, as exemplified by the 
Seidlitz powder or by the effervescing magnesium cit- 
rate or Rochelle salt, or castor oil if that is preferred. 
If the patient is seen first in the evening, a less quickly 
acting cathartic is advisable, and none is better than a 
small dose of calomel, as from 0.05 to 0.20 gm. (about 
1 to 3 grains), depending on the age of the individual, 
combined with 0.50 to 1 gm. (7y 2 to 15 grains) of 
sodium bicarbonate. Or, 1 grain of calomel may be 
given with an ordinary compound aloin pill or tablet. 
The old-fashioned Dover's powder is still given by 
many physicians and often works well, but may cause 
considerable nausea. Also, opium or morphin in any 
form tends to inhibit free action of the bowels, which 
is undesirable. One of the best treatments is one of 
the coal-tar products, such as antipyrin, acetanilid or 
acetphenetidinum. Any one of these may be given in 
one fair-sized dose or in two medium-sized doses, or in 
several small doses. One gm. of antipyrin would be a 
full dose ; 0.50 gm, repeated in five or six hours, would 
be a medium dose; 0.30 gm. of acetanilid would be a 
large dose, and 0.10 gm. might be repeated at three- 
hour intervals for three times. A satisfactory method 
is a combination of acetanilid with sodium bicarbonate, 
and a prescription similar to the following is often 
very valuable : 

Gm. 

B Acetanilidi 0|25 or gr. v 

Sodii bicarbonatis 2|50 gr. xl 

M. et fac chartulas 5. 

Sig. : One powder every two or three hours. 

A similar combination may be given in tablets, if 
preferred. It should be remembered that caffein has 
been shown not to protect the heart from depression 
caused by large doses of a coal-tar product ; therefore, 
there is no object in adding caffein to such a prescrip- 
tion. When these coal-tar products are ordered, it is 



210 RHINITIS TABLETS 

well to give coincidently hot lemonade. Perspiration 
is more readily caused by this means. 

Provided the patient is not soon to be subjected to 
exposure, a hot bath is another efficient means of 
relieving internal congestions, and can be used coinci- 
dently with the other treatment. Acidum acetylsali- 
cylicum (aspirin) is now more largely used than 
almost any other drug to abort colds. The laity, on 
account of the instruction which they have received of 
the dangers of acetanilid and similar drugs, now all 
buy and use this drug with the greatest freedom. It 
can cause cardiac depression, and should not be used 
ad libitum. If preferred, it may certainly be ordered. 

Rhinitis tablets are sold everywhere to the laity, and 
are largely used by physicians. These are various 
combinations of morphin, atropin, strychnin and aconi- 
tin. The minute dose of aconitin ordered probably 
generally has no action. If one desires the activity of 
aconite, it is best to give it in a tangible form and dos- 
age, namely, the tincture of aconite, a drop perhaps 
every half hour or hour, until the pulse shows the 
activity of the drug. However, this treatment ordin- 
arily requires that the patient be seen within a certain 
number of hours by the physician, to ascertain whether 
or not the aconite should be stopped, unless the doses 
are limited in number. The old aconite treatment of 
colds has mostly given place to the newer treatments 
described above. The whole rhinitis tablet combina- 
tion probably represents principally the action of 
atropin with some help from the morphin, both of 
which will dry up the secretions of the nostrils and 
throat. The small amount of strychnin probably is 
not very active. Sometimes minute doses of quinin 
enter into these combinations, but that probably is not 
active. In other words, it is a question if a small dose 
of atropin sulphate, given frequently, does not act as 
well as one of these rhinitis combinations. 

There is no question about the drying up of secre- 
tions by morphin, if this drug is pushed. Rarely is 
such treatment needed. The old-fashioned treatment 
of a hot foot-bath, a hot whisky punch, and the patient 
put to bed is a treatment that is often successful. The 
upper air passages and the head arc relieved from con- 
gestion- by such treatment, the blood-vessels of the 



SPRAYING SOLUTIONS IN CORYZA 211 

surface are dilated by the alcohol, and the patient per- 
spires more or less and the treatment is conducive to 
comfort. In this age, however, when other vasodi- 
lators are accessible, it is rarely necessary to resort to 
alcohol. 

Quinin sulphate has been used for years as an abor- 
tive treatment of colds, and the laity, until more 
recently adopting acetylsalic) lie acid, have always 
resorted to this drug. Small doses would probably 
not have any very decided action; large doses are 
inadvisable at this stage of the congestion because of 
the tendency to congest the middle ear. 

Spraying or snuffing solutions into the nostrils at 
this stage is inadvisable. The throat may be gargled 
with warm physiologic saline solution, which is 
roughly represented by % teaspoonful of salt to half a 
glass of warm water. If the patient has been known 
to be exposed to some acute throat or nasal infection, 
more active antiseptic gargles and sprays may be used ; 
but an acute coryza will rarely be aborted by local 
treatment. 

If the inflammation is not aborted and the second 
stage develops, that of profuse mucus and some muco- 
purulent discharge, then cleansing of the nose and 
throat becomes urgently needed. At this stage all of 
the foregoing abortive measures should cease. A 
patient who has been more or less deprived of food, 
except a small amount of liquid nourishment for from 
twenty-four to thirty-six hours, may now resume his 
normal diet. 

The more or less purulent discharge from the nos- 
trils should not be allowed to remain blocking up the 
passages. Consequently, atomizing with warm saline 
and alkaline solutions should be more or less fre- 
quently done. Various compound solutions or tablets 
for solution are offered, but there probably is no ad- 
vantage in these combinations over more simple ones. 
The simplest cleansing solution is one made from y 2 
teaspoonful of salt and y 2 teaspoonful of sodium bicar- 
bonate to a glass of warm water, or half these amounts 
for half a glass of water. To be properly soothing, the 
solution should always be warmed. The same solu- 
tion may be used as a gargle. If a mild antiseptic is 



212 TONIC TREATMENT IN CORYZA 

needed, saturated solutions of boric acid or borax are 
efficient. If stronger antiseptic solutions are required 
or advisable, hydrogen peroxid is valuable, as 1 part 
of the official aqua hydrogenii dioxidi to 4 or 5 parts 
of warm water for a gargle, or 1 part to 7 or 8 parts of 
warm water for a nasal spray. Nasal spraying and 
proper cleansing of the nose protects the adjacent 
sinuses from infection. 

Cleansing the nasopharynx by snuffing back a solu- 
tion from a teaspoon or a small vial, or snuffing back 
a spray, or gargling and then throwing the head for- 
ward and washing the nasopharynx, protects the 
eustachian tubes from infection. Two cautions should 
be suggested : first, that douching of the nasal passages 
should not be done with the nostril blocked, or with a 
high placed douch reservoir, as the pressure is likely 
to be sufficient to send fluid into the eustachian tubes 
or into the sinuses, and cause inflammation of such 
parts. Most of the patented douch apparatus are inad- 
visable. The second precaution is that it is not well to 
cleanse the mucous membrane of the nostrils too thor- 
oughly of mucous before the patient goes into the out- 
side air, especially if that air is dust-laden. The proper 
time to spray is when the patient is to remain in the 
house for a short time ; or if he is sprayed and then 
must go out of doors, he may receive a non-irritant oil 
spray to furnish a coating for the mucous membrane, 
this to be used after the alkaline spray. Or a small 
plug of cotton may be placed in the nostrils. 

If the secretion from the nose is tenacious and hard 
to dislodge by blowing the nostrils, ammonium chlorid 
may be a drug of value. It has been used as a stimu- 
lant to the upper air passage mucous membrane as well 
as to the bronchial mucous membrane. It may be 
given in a simple preparation as : 

Gm. or c.c. 

Ifc Ammonii chloridi 5 3 iss 

Syrupi acidi citrici 25 or fl.3 i 

Aquae q. s. ad 100 fl.3 iv 

M. ct Sig: A teaspoonful, in water, every three hours. 

If the coryza tends to become subacute and pro- 
longed, tonic treatment is required ; a small dose of 
quinin and a small dose of iron, with or without 



ACUTE PHARYNGITIS 213 

arsenic and strychnin, are advisable. Or calcium gly- 
cerophosphate may be given in doses of 0.30 gm. (5 
grains) in capsule, three times a day, after meals. 
The following tonic capsule may be used, and the 
doses may be modified for a child : 

Gm. 

R Arseni trioxidi 0|04 

Strychninae sulphatis 0|04 aa gr. y^ 

Ferri reducti 110 or gr. xv 

Quininae sulphatis 2|0 gr. xxx 

M. et fac capsulas siccas 20. 

Sig. : A capsule three times a day, after meals. 

If the mucous membrane of the nose and throat does 
not return to health, and the secretion of mucous does 
not seem to be sufficient, a great promoter of secretion 
is an iodid, and the best salt is the sodium iodid. The 
dose required is not large; 0.10 to 0.20 gm. (lj^ to 
3 grains) three times a day, is generally sufficient. 

Various menthol, camphor and pine oil prepara- 
tions are used as sprays or applications for the nos- 
trils, sometimes with good results, or as inhalants when 
the nostrils tend to become closed and cause discom- 
fort by occlusion. Such treatment has its use at times. 
Spraying with suprarenal solutions is sometimes of 
advantage, but sometimes is followed by more conges- 
tion. Some nose and throat specialists use suprarenal 
preparations constantly. Such treatment certainly 
many times is efficient in temporarily relieving conges- 
tion and giving comfort. 

This discussion of the treatment of common colds 
would not be complete without reference to the vaccine 
treatment. While the exact value of such treatment 
has not been determined as an abortive treatment or as 
a treatment that shortens the course of the disease, the 
enthusiastic recommendation of such treatment by 
some writers should be recognized. When there is 
sinus infection, autogenous vaccines would seem indi- 
cated. 

ACUTE PHARYNGITIS 

The abortive treatment of this inflammation is the 
same as that described for acute colds. 

With a simple pharyngitis, soothing alkaline gargles, 
as previously described, should be the treatment. A 



214 COUGHS 

very simple, pleasant and efficient gargle is as fol- 
lows : 

Gm. or c.c. 

3 Acidi borici 21 3 ss 

Potassii chloratis 5| or 3 iss 

Aquae menthae piperitae. . . . 200! fl.3 vii 

M. et Sig. : Use undiluted as a gargle, every three hours. 

COUGHS 

Before discussing the infections of grip and whoop- 
ing-cough, it may not be out of place to refer to the 
varying kinds of cough. Only by careful observation 
can the early stages of whooping-cough be suspected 
and discovered. 

Coughing is an expiratory effort caused reflexly by 
some irritation. The muscles of the lower part of the 
chest are most engaged in the act of coughing; hence 
in severe, prolonged or frequent coughing muscle tire 
occurs in the lower part of the chest, both anteriorly 
and posteriorly. The abdominal muscles all take part 
in this expiratory effort, and the erector spinae mus- 
cles, the serratus, and the quadratus lumborum are 
all utilized in a strong expiratory cough. These mus- 
cle contractions compress in all directions the lower 
part of the chest, and the air in the bronchial tubes 
is forced upward, and if there is no obstruction is 
expelled through the glottis. If there is obstruction, 
or even partial obstruction, the upper portion of the 
lungs, especially the apices, become dilated, and tem- 
porarily, or in severe cases, permanently, emphysema- 
tous. 

Cough can be caused by irritation of any of the 
mucous membranes of the air tract, by irritations of 
the nerves in the lung tissue, by irritations of the 
pharynx, by reflex irritation of the vomiting center, 
and by any irritation that can reach, through the 
pneumogastric nerve, the center in the medulla. From 
any of these reflex causes efferent impulses are trans- 
mitted, and the result is a cough. Irritation in the 
nose and ear may cause cough. 

Pain and muscle tire from prolonged coughing, 
besides occurring in the lower part of the chest, occur 
in the sides, low down, perhaps in the region of the 
insertion of the diaphragm, and also in the back even 



TYPES OF COUGHS 215 

down in the lumbar region. These strong contrac- 
tions of the abdominal muscles during coughing also 
aid in temporarily diminishing the capacity of the 
thorax by pushing upward the abdominal organs. At 
the same time there is a considerable force exerted 
downward, which may tend to cause uterine displace- 
ments, hemorrhoids and even involuntary urination. 

Before this forcible expiration or cough there is 
generally a deep, quick inspiration ; then the glottis is 
partially closed and the air is propelled upward for- 
cibly, causing friction which tends to expel anything 
on the walls of the mucous membrane of the bronchial 
tubes and trachea. Even in simple bronchitis, if 
there is much coughing, there will be found increased 
resonance in the apices of the lungs, as there is prob- 
ably always a temporary emphysema. 

Nasal irritations may produce cough as frequently 
as they cause asthma. Irritations of the nasopharynx 
and pharynx proper frequently cause coughing, which 
is very likely to be accompanied by retching and even 
vomiting. An elongated uvula may tickle the epiglottis 
and cause spasmodic, quick expiratory coughing. This 
cause, however, is rare compared with the frequency 
of cough caused by an enlarged lingual tonsil, whether 
the tonsil is hypertrophied, contains dilated blood- 
vessels, or is inflamed. Any disturbance of this gland 
or lymphoid tissue may cause a tickling in this region 
sufficient to produce a very irritating and disturbing 
dry cough, which comes on sometimes in paroxysms, 
until a certain amount of mucus is literally scraped off. 
The very intensity of the cough so irritates the part, 
like scratching a spot on the skin that itches, as to 
stop the tickling sensation for a time. Irritations of 
the larynx almost always cause cough. Hence no 
examination of a patient who coughs is complete with- 
out a throat and larynx observation. 

The dry bark of spasmodic croup is very character- 
istic. The noise is low pitched, and is a bark. If it 
is husky there is mucus or membrane present. 

The cough of bronchitis can be of all descriptions ; 
it may be dry, may be non-productive, and may be 
moist and productive. Pain in such cough (the same 
is true of grip) is referred under the sternum, and is 
due largely to the vibrations of the air causing pain to 



216 TYPES OF COUGHS 

the inflamed mucous membrane of the trachea and per- 
haps larger bronchi. 

The cough of pneumonia is at first somewhat pain- 
ful, and the pain is referred to the side, near the 
nipple. This cough may be at first dry, but is soon 
productive and generally should be encouraged. 

The cough of pleurisy is non-productive and unde- 
sired, and is never loud. It causes pain referred to 
the side, and is repressed by the patient. There is 
nothing to expectorate, and it should be discouraged 
and stopped. 

The cough in the first stage of tuberculosis is often 
dry and catchy ; it is a hack. There is no great inten- 
sity to this cough, and no necessity for it, and it 
should be discouraged. As soon as there is much local 
bronchial catarrh the cough should, as it is then pro- 
ductive, not be discouraged, except at meals, and in 
the presence of others ; that is, such patients should 
be taught when to cough. 

The cough of asthma is a wheezing affair and ac- 
companied by all sorts of rattlings ; the same type 
occurs in a stuffy, asthmatic bronchitis. This cough is 
generally not harsh. 

The coughs of different individuals vary. Some 
always cough with great intensity, and others easily 
and lightly. Older persons seem to raise mucus and 
pus from the bronchial tubes with difficulty. It takes 
a great many coughs to raise the sputum for expecto- 
ration. Young children generally cough easily, but 
generally swallow their sputum. Very weak patients 
will hardly expectorate at all. In such cases the foot 
of the bed may be raised at night; also when they 
cough while in bed, they should turn onto the side or 
stomach in order to raise the sputum, or they should 
lean over in order to have gravity aid as much as 
possible the expulsion of the mucus, etc. The cough 
of pertussis occurs in showers or paroxysms, and at 
the height of the disease the glottis closes during in- 
spiration and the air is sucked in through a more or 
less narrow slit, giving the characteristic "whoop." 

Persons coughing very hard, as typically in whoop- 
ing-cough, but also in emphysema and in the severe 
bronchitis of strong, sturdy men, will cause a great 
deal of cardiac disturbance by retarding the flow in 



ACUTE BRONCHITIS 217 

the large vessels of the thorax, thus increasing the 
work of the heart, especially of the right side. Such 
coughing can force backward the blood in the large 
veins thus congesting all the organs, notably the eyes, 
face and head, and whooping-cough can cause a cere- 
bral hemorrhage or a hemorrhage into the eyes. These 
patients may not infrequently have nosebleed, and even 
vomit blood. 

ACUTE BRONCHITIS 

There is no question that, whether bronchitis occurs 
in an adult or in a child, the patient will recover more 
quickly if he remains in bed for one or more days. 

The prophylactic treatment is the same as for an 
acute coryza, and these treatments will more or less 
relieve the congestion in the bronchial tubes and pro- 
mote expectoration, if the disease is not aborted. The 
cough is at first non-productive, but as soon as mucus 
begins to be plentifully expectorated the cough is pro- 
ductive, the tightness in the chest is relieved, and the 
patient feel better. One of the best promoters of a 
free mucus secretion is ipecac, and a few drops of the 
syrup of ipecac, given every hour, unless nausea is 
caused; or from 0.03 to 0.05 gm. (about y 2 to 1 grain) 
of the powdered ipecac may be given every two hours. 
The ipecac should never be pushed to the point of 
causing uncomfortable nausea. The dose should, 
therefore, as suggested, be very small. 

In the second stage of bronchitis there is no expecto- 
rant that seems to work so well as ammonium chlorid, 
and the dose should be about 0.25 gm. (4 grains) every 
two hours. The bad taste of this drug may be well 
covered up by giving it in a sour mixture, as the syrup 
or citric acid and water. If the cough is excessive and 
more than the secretion calls for, there is possibly no 
better method for its control than to give small doses 
of codein sulphate. This may be combined with the 
ammonium chlorid in a sour mixture, as : 



Gm. or c.c. 

Ifc Codeinae sulphatis ; 

Ammonii chloridi 5 

Syrupi acidi citrici 25 

Aquae q. s. ad 100 

M. et Sig. : A teaspoonful, in water, every two or three 
hours. 



20 gr. iv 

3 iss 

fl.Siv 



218 TREATMENT OF BRONCHITIS 

This prescription is for an adult, but may be readily 
modified according to the age of the child. If the 
codein is not desired, it may be omitted. If it is 
desired to give the ammonium chlorid less frequently, 
the dose may be made larger. If a sweeter mixture 
is preferred, the syrup of tolu may be substituted for 
the syrup of citric acid; or both the syrup of citric 
acid and the water may be omitted and the syrup of 
wild cherry substituted. 

If the larynx is inflamed, the inhalation of simple 
steam, or various other inhalants, may be of value, 
but a patient with laryngitis of any type should be 
under very careful observation by a physician. 

If the expectoration becomes more profuse and 
seems not to stop readily, terpin hydrate seems to be 
of value. The dose is 0.30 gm. (5 grains) about four 
times a day. This may be given in tablet or in powder ; 
solutions are unsatisfactory as it is very insoluble. If 
deemed advisable it may be combined with codein or 
heroin in small doses. There is, however, no real 
advantage in heroin over codein. 

If the coughing persists longer than a week, the 
sputum should be examined to determine what germs 
are present. If it proves to be a simple bronchitis, 
but prolonged, sodium iodid in small doses may be 
of value, especially if the patient is at all asthmatic, 
or if it is. in an older person. Fresh air, good food and 
iron are always of value in curing all kinds of bron- 
chitis. If the patient is a child and the nutrition is 
poor, cod-liver oil is good treatment. A bronchitis 
that will not stop must be treated as a pre-tuberculous 
stage of tuberculosis, and the patient should receive 
climatic, or open air rest cure treatment. 

It should be emphasized that a patient with bron- 
chitis is not properly supervised unless the tempera- 
ture is taken, and this more or less frequently. A 
patient with a fever should remain at home, if he 
wishes to avoid complications that readily occur from 
an acute bronchitis or grip. The district nurse or the 
medical inspector should always lake the temperature 
of a coughing child. If a child has any fever, it should 
be sent home and the family physician summoned. 



INFLUENZA 219 



INFLUENZA: GRIP 



While the well-known acute epidemic types of this 
disease probably always show the influenza bacillus, it 
is not always discovered in instances that seem similar 
and are well termed grip or influenza, as distinct from 
an ordinary cold or bronchitis. The small blood-ves- 
sels all over the body seem to dilate and produce 
capillary congestion, especially of the mucous mem- 
branes, the most frequent result being a coryza, a 
pharyngitis, a laryngitis or a tracheitis. The conges- 
tion in the larynx causes the harsh, dry, metallic cough 
which is quite characteristic of this type of influenza. 
The congestion and swelling of the mucous membrane 
of the trachea causes a peculiar oppressed feeling with 
more or less pain, referred to the upper part of the 
sternum. The great amount of sneezing which occurs 
with a typical attack, almost similar to hay-fever, is 
due to congestion of the mucous membrane of the 
nostrils. The conjunctivae may also be injected, caus- 
ing pain in the eyeballs and often a serous conjunc- 
tivitis, another typical symptom of influenza. In some 
seasons there seems to be a special tendency to middle- 
ear inflammations. At other times there frequently 
occurs a congested drum, with sometimes a hemor- 
rhagic bleb or vesicle on the drum, a very painful 
though easily remedied condition. 

The almost constantly present lumbar backache at 
the onset of this disease is probably due to congestion 
of the kidneys, and albumin is frequently found in the 
urine of such patients, and occasionally blood-cor- 
puscles. A menorrhagia or a metrorrhagia may occur 
from the same tendency to dilatation of the blood- 
vessels. There may even be nosebleed, and occasion- 
ally a slight hemoptysis without any other assignable 
cause and without any subsequent development. With 
this disease, although the fever may be high, the skin 
is likely to be moist, and there may be a profuse per- 
spiration. The pulse may be slower than we normally 
expect from the height of the fever, and the blood- 
pressure is generally lowered; all of these conditions 
are due to the tendency of the blood-vessels to dilate. 

The heart is generally weak from start to finish in 
this disease, and even collapse turns can occur. 



220 INFLUENZA 

Rather an infrequent type of the disease is the 
bowel type; this can occur without respiratory catar- 
rhal symptoms. Patients so affected have diarrhea, 
with more or less intestinal irritation, apparently the 
greatest amount of dilatation of blood-vessels in these 
cases occurring in mucous membrane of the intes- 
tinal tract. These various types, the catarrhal, the 
nervous and the abdominal, may be interwoven, and a 
patient may show symptoms of all three. 

The future of every case of influenza is prostration, 
nervous and muscular debility, with more or less cir- 
culatory weakness ; in other words, there is exhaustion. 
The patient's resisting power is reduced, and any 
defect or diseased condition that he may have is aggra- 
vated by an intoxication with this germ. 

If no complications occur, the convalescent patient 
should rest as much as possible, should not be sub- 
jected to exposure and should be given tonics, and, if 
necessary to cause restful sleep, for a short period at 
least, some hypnotic or some physical method of caus- 
ing sleep. The most frequent complication is pneu- 
monia, and the type of pneumonia that the influenza 
germ seems to cause most frequently is the lobular or 
bronchial pneumonic type ; pneumonic congested areas 
may be found in different parts of one or both lungs. 
Not infrequently, however, true lobar pneumonia 
occurs. 

The next most frequent complication, as suggested 
above, is middle-ear catarrh. The various sinuses in 
the region of the nostrils may become affected ; all 
types of indigestion may occur, and not only sleepless- 
ness and meningismus, but also a very serious menin- 
gitis, and even insanity can be caused by these germs 
and their toxins. Mental depression is a common 
occurrence, following severe attacks of grip. Peri- 
carditis and endocarditis occur as complications of 
influenza. 

It is thus seen that this disease should always be 
taken seriously, and every possible means used to pre- 
vent contagion, as it is one of the most highly con- 
tagious diseases. It spreads with great rapidity, but 
only by contact, although it may doubtless be trans- 
mitted by infected clothing, and perhaps even by let- 
ters, as when the last epidemic first reached America, 



TREATMENT OF INFLUENZA 221 

the first persons affected in many cities were post- 
office clerks. 

While no season is exempt from this disease, it 
occurs most frequently in colder weather, and in the 
colder climates, and in moist climates. Perhaps the 
more sunshine, the less frequent the disease. While 
one attack may protect a person for that season, he 
seems more susceptible to subsequent attacks in fol- 
lowing years. There are doubtless many carriers of 
this disease who may have a persistent and continued 
subacute or chronic catarrhal infection and very likely 
are distributers of the disease to others. When one 
case occurs in a household, other members of the 
family become readily infected. The same is true in 
schools and in stores or buildings in which an infected 
person is closely associated with others. Many an 
office with one employee affected will soon, on investi- 
gation show every other employee to be more or less 
seriously affected. While almost all persons are sus- 
ceptible to this disease, a few seem to be immune. 
It is the most frequent of all definite infectious dis- 
eases. 

TREATMENT 

It having been determined or suspected that a 
patient has influenza, it is much more important that 
he remain in bed, or at least in the house, than if he 
has an ordinary acute cold. Also, it is more essential 
that he be more or less isolated or that measures be 
taken that he does not spread the disease by spraying 
from coughing or sneezing, and that he does not use 
the same towels, napkins, drinking-cups and eating 
utensils as other members of his family. The patient 
should be prohibited from fondling and kissing chil- 
dren. If the patient is a young child in close contact 
with the mother or nurse, all possible precautions to 
prevent contagion should be taken. 

In a word, each family should be taught that grip 
is an infection, that it is contagious, that it spreads 
rapidly, that it may have serious complications and 
that it frequently leads to pneumonia, which has 
become in many regions of this country the most fre- 
quent cause of death. Therefore, even an apparently 
mild case of grip or influenza should be treated actively 



222 GENERAL TREATMENT OF INFLUENZA 

and energetically. As previously stated, whether a 
schoolchild begins with an acute cold or an influenza, 
he should be sent home and remain there until he is 
well, or at least almost well. 

As a grip patient is liable to have a chill, or at least 
feel chilly or have cold sensations up and down the 
back, anything that makes him warm improves his 
condition. He may be given hot malted milk, hot tea 
or hot lemonade, at more or less frequent intervals, 
until his chilliness has ceased. The patient may be 
given a hot tub bath and then put into a warm bed in 
a warm room as an efficient means of making him 
comfortable and relieving his internal congestions. 
Hot water bags at the feet and extra coverings to the 
bed are often needed. A quickly acting stimulant is 
aromatic spirits of ammonia, given in half teaspoon- 
ful doses in hot water or hot lemonade, at intervals of 
three hours, for three or four times. The various 
methods suggested for aborting an acute cold may be 
used in this disease. Much greater care must be exer- 
cised, however, if the patient has the influenza infec- 
tion than if he has a simple cold, as to when he can 
return to his work or occupation, or be subjected to 
exposure to cold or dust, either in a house, building or 
outdoors. 

As soon as the patient feels warm, the temperature 
may rise quite high, associated with severe headache, 
backache and irregular pains in other parts of the 
body. At this time a drug such as acetanilid, antipyrin, 
acetphenetidinum, or acetylsalicylic acid will be of 
benefit, provided that the patient is not ambulatory, 
and that he is not to be subjected to exposure. With 
this depressing infection such treatment is not wise 
unless a patient is in bed, or at least remains in the 
house. 

The proper dosage of these drugs has already been 
suggested, and no one of them should be long con- 
tinued. The most depressant is undoubtedly acet- 
anilid, and perhaps the least depressant is acetphen- 
etidinum. Should depression occur after one of these 
drugs has been administered or from the disease, cir- 
culatory stimulants such as aromatic ammonia, cam- 
phor or caffein should be given and the patient sur- 
rounded with dry heat. A hypodermatic injection of 






DRUGS IN INFLUENZA 223 

strychnin sulphate, 1/30 grain, may be given to stimu- 
late the nerve centers. Cyanosis has not infrequently 
been caused by acetanilid, but an amount of this drug 
large enough to cause such a condition should never be 
given. The following prescription may be suggested : 

Gm. 

fy Acetanilidi 0150 gr. viiss 

Sodii bicarbonatis 1 [0 gr. xv 

M. et fac chartulas 10. 

Sig.: One powder, with water, every two hours, except when 
the patient is sleeping. 

Gm. 

I£ Acetphenetidini 1 150 

Phenylis salicylatis 1 150 aa gr. xxv 

M. et fac chartulas 5. 

Sig. : One powder every three hours. 

It should be remembered, as previously noted, that 
it has been shown that an alkali like sodium bicar- 
bonate inhibits the undesired action of coal-tar drugs 
on the heart ; also, that caffein does not protect a heart 
from undesirable activities of the coal-tar drugs; in 
fact, it has been shown to intensify such activity. 

In making a diagnosis of the infection present it 
is well to remember that any of these drugs, and also 
salicylic acid in any form, may cause eruptions on the 
skin, either erythematous or urticarial. 

But little food is needed during the first twenty- 
four hours of grip, and it should not be pushed even 
on the second day, if food is repugnant to the patient. 
He should have plenty of water and such simple liquid 
nourishment as he desires. As soon as the appetite 
returns, food should be pushed. The various catarrhal 
conditions should be treated as suggested under coryza, 
pharyngitis and bronchitis. Also, while the patient is 
kept warm, he should have good fresh air in his room. 
This is essential with all infections, and especially 
with infections of the nose, throat and lungs. The 
bowels should be treated as indications call for. 
Simple laxatives may be given, if needed, or the sooth- 
ing bismuth subcarbonate, if there is intestinal inflam- 
mation. Phenyl salicylate (salol) may be given, if 
there is much fermentation in the bowels, or the 
Bulgarian form of lactic acid bacilli may be given for 
a few days. 



224 ASTHMA 

As soon as the patient begins to convalesce, he 
should be given tonics, and if there is no inflammation 
in the ears, quinin is valuable. Some form of iron 
should generally be given, and possibly a bitter tonic 
before meals. If the patient is not nervous, a small 
dose of strychnin three times a day is good treatment. 
On the other hand, it should be urged that strychnin 
stimulation is overdone, and a patient who cannot sleep 
should not be given strychnin or quinin later than the 
noon meal. Sometimes the sleeplessness following 
influenza is benefited by the administration of one-half 
to one teaspoonful of good fluidextract of ergot, taken 
an hour before bedtime. These patients should never 
be allowed tea or coffee after the noon meal, as they 
are very susceptible to cerebral stimulation by caffein 
and are likely to remain awake for hours from such 
stimulation. All disturbances or diseased conditions 
left over by grip must be treated energetically, else 
they tend to be prolonged. There are few germs that 
seem to be so tenacious and persistent, at least in their 
unpleasant results, as is the influenza bacillus. All 
persons are susceptible to serious consequences from 
influenza. 

ASTHMA 

In the first place, the disease asthma should be disso- 
ciated from conditions which are termed asthmatic. A 
patient may be asthmatic from various causes, but the 
term asthma should be limited to the disease or condi- 
tion itself, i. e., periodic attacks of bronchial spasm. 
More or less continued dyspnea, with or without 
whistling rales, and with or without acute attacks of 
asthma, may be caused by cardiac disease, cardiac 
asthma ; by renal insufficiency, renal asthma ; by pleth- 
ora, causing attacks of acute hyperemia of the lungs ; 
by arteriosclerosis ; emphysema ; diabetes ; thyroid dis- 
turbances, and by the various anemias. Spasmodic 
asthma may be caused by bad heart attacks ; by acute 
toxemia from renal insufficiency ; by exacerbations of 
gout, probably due to a toxemia from nitrogenous mal- 
metabolism; by acute indigestion, and by gastrointes- 
tinal irritants causing a swelling of the mucous mem- 
branes of the bronchial tubes, really an urticaria. This 
swelling of the mucous membrane of the bronchial 
tubes has been caused by injections of horse serum. 



CAUSES OF ASTHMA 225 



CAUSES 



The diseased condition, or neurosis, termed true 
asthma, is often due to irritation of the nose and 
throat, and sometimes of the ear; is frequently due to 
chronic bronchitis, often is concomitant with acute dis- 
turbances of the mucous membranes of the upper air 
passages, as when caused by irritations from pollen, 
such as hay fever, rose fever, and by various dust and 
drug irritants. Asthma, however, is frequently a sim- 
ple neurosis. 

An attack of asthma generally occurs at night, and 
may be preceded by headache, some symptom of indi- 
gestion, mental depression or nervous irritability. 
There is at first some slight dyspnea and a short dry 
cough. The dyspnea and consequent cardiac distress 
increase, and the agony suffered by these patients can 
not be understood unless one has seen them suffering 
from an attack of this terrible disease. The agony is 
almost as great as that of acute cardiac dyspnea, al- 
though there is not so much mental anxiety. The pa- 
tient may be pale or almost livid, and the expression of 
the face shows the suffering due to attempts to inspire, 
and then to expire, through the contracted bronchial 
tubes. The muscles of inspiration being stronger than 
the muscles of expiration, for a time more air enters 
the lungs than can get out, and little by little there is 
increased chest distention. Percussion shows hyper- 
resonance. The greatest amount of wheezing, as 
shown by the stethoscope, is in expiration, and the 
expiration is prolonged in the attempt to empty the 
lungs and prepare them for the next inspiration. If 
the bronchial secretion begins, as it generally does, 
moist rales may also be heard, and, after a series of 
spasmodic efforts, the cough brings up white glairy 
mucus. 

The length of these attacks of acute asthma, if un- 
relieved, varies from an hour or two to all night, and 
sometimes an attack may last several days. Occasion- 
ally the attacks last for many hours, or even days, in 
spite of all treatment, and any temporary relief given 
by powerful drugs may not prevent the resumption 
of the asthmatic spasm the moment the patient is out 
of the influence of the drug. The amount of dyspnea 



226 TREATMENT OF ASTHMA 

that the patient has, and the amount of suffering and 
the seriousness of the attack, do not bear a close rela- 
tion to the amount of wheezing that is heard. A 
patient may not suffer greatly from dyspnea so long 
as he is sitting upright, and yet be wheezing like a de- 
crepit old horse. 

The longer the paroxysm lasts and the more intense 
it is the greater the danger of permanent injury to 
the heart and the greater the danger of the distention 
of the chest, so injuring the lung tissue as to make 
the emphysema permanent. Even after repeated at- 
tacks most patients have no cardiac injury and no 
lung injury, but this is doubtless because most of those 
who suffer from acute asthma are young; the older 
patients do have more or less lasting bronchitis, heart 
debility and more or less constant dyspnea and often 
emphysema. It is rare for a patient to die during an 
attack of acute asthma, but the condition should al- 
ways be considered serious, as it could never be de- 
cided how much future disability was caused by the 
prolongation or repetition of such serious disturbance 
of the vital functions of respiration and circulation. 

Acute attacks of asthma may occur every night for 
a series of nights, and then not for a long period, or 
after one attack there may be no more for some time, 
or they may occur more or less periodically, or they 
may recur only at certain periods of the year or in 
certain places. These last are likely to be due to nasal 
irritations. The attacks may also occur more or less 
frequently for several years, or even for a lifetime. 

GENERAL TREATMENT 

The opinion is gaining ground that asthma is a form 
of anaphylaxis. The physician should endeavor to as- 
certain what type of hypersensitiveness each case 
presents. 

The treatment of this troublesome disease, or condi- 
tion, will never be a success unless the cause has been 
determined, and, if possible, removed. Hardly any 
patient with any disease should receive a more careful 
general examination than the asthma patient. The 
lungs must be carefully examined for bronchitis and 
emphysema, and more serious conditions found or 



DRUGS IN ASTHMA 227 

eliminated, and the blood pressure taken. The diges- 
tive ability of the stomach and intestines should be in- 
vestigated, the urine should be examined, and all pos- 
sible reflex causes sought in the throat, nose or ears. 
If all tangible causes of the asthmatic attacks have 
been eliminated, a careful analysis of the excretion of 
the various salts and solids in the twenty-four hours' 
urine, on a known diet, should be made. Even careful 
examinations of the feces, on a known diet may give 
conclusive evidence of the cause of the toxemias that 
give rise to asthma. So much for negative evidence. 

DRUGS IN ASTHMA 

Perhaps the most frequently successful drug in pre- 
venting the recurrence of asthma is an iodid, and this 
is probably because most asthma is due to affections of 
the air passages, and this drug is specifically a stimu- 
lant to the mucous membrane of the nose, throat and 
bronchial tubes. If any chronic disturbance is located 
in these mucous membranes the iodid tends, first, to 
increase the exudate from these membranes, then to 
make the mucus more liquid, and, while at first appar- 
ently irritant, soon relieves congestion of these mem- 
branes, and often, sooner or later, cures a chronic con- 
gestion and causes the membrane to become healthy. 
Hence the frequency of success from iodid simply em- 
phasizes the necessity of a careful examination for, 
and the removal, if found, of any nasal obstructions 
or irritations. After such removal, a sensible treat- 
ment to prevent the recurrence of attacks would be 
the prolonged administration of iodids, and very large 
doses are seldom needed, or if the history of the attack 
shows long standing of the disease, the treatment of 
the neurosis by bromids is advisable, and here again 
the dose should not be large. We should not produce 
debility either with iodid or with bromids. 

Arsenic, a so-called alterative drug, seems at times 
to have a specification on the respiration. In chronic 
bronchitis, in asthma, in catarrhal conditions of the air 
passages, arsenic, when given for a long period, is 
sometimes of considerable benefit. The respiratory 
ability and freedom from colds and coughs of the 
arsenic eaters of France and the Alps is well known. 



228 GENERAL TREATMENT IN ASTHMA 

A local cause in the upper air passages having been 
removed, if there was any such, besides treatment 
either by iodids or bromids, if either one is deemed ad- 
visable, anything that will improve the general health 
of the individual should be utilized. An occupation in 
which there is an atmosphere of dust or other irritant 
should be changed for one more suitable. Perhaps 
indoor work should be changed for outdoor work, per- 
haps the climate or location should be changed. Any 
indigestion, gastric or intestinal, should be corrected; 
constipation should be prevented; anemia should be 
treated, and insufficiency of the thyroid, if present, 
should be noted and modified. 

If asthma recurs at certain periods of the year as 
does hay fever, the preventive treatment is the same 
as for hay fever. Anything that will reduce the nasal 
irritations and congestions will relieve the asthma, and 
any change in location that will prevent the hay fever 
will generally prevent the asthma. To just what local- 
ity or climate an asthmatic patient should be sent is 
difficult to determine. Also, it is impossible to predict 
that, because one patient is benefited by a sojourn or 
residence at one particular place, that place will be 
beneficial to the next patient. Theoretically, regions 
free from dust and vegetation should be the regions 
to prevent attacks of asthma. Sea voyages are some- 
times beneficial and sometimes not. The decision as 
to whether or not benefit will be derived from certain 
regions may often be determined by a careful investi- 
gation into the condition of the patient's mucous mem- 
branes and the condition of his circulation. 

Anything that would tend to make the circulation 
better in the mucous membranes of the upper air pas- 
sages and diminish congestion and tumefaction of the 
mucous membranes of all the air passages will tend to 
prevent recurrences of asthma. Cardiac insufficiency, 
of course, should be properly treated, and whether the 
heart needs digitalis or the arteries need nitroglycerin 
or nitrites continuously, or whether the general good 
effect of ergot on the circulation is needed (and asthma 
may sometimes be prevented by ergot) must be de- 
termined by a careful study of the individual patient. 

Insufficiency of the kidneys as a cause of asthma 
should be treated by the proper diet and the preven- 



TREATING PAROXYSM IN ASTHMA 229 

tion, if possible, of nitrogenous toxemias. Such 
asthma is an indication of nitrogenous poisoning. The 
asthma due to gout is often best combated with thyroid, 
and when there is insufficiency of the thyroid in young 
individuals, which may be recognized by well-known 
signs, such as amenorrhea or scanty menstruation in 
women, an unusual and undesirable increase of fat, 
a dry condition of the skin, and a tendency to nitrogen- 
ous poisonings, the asthma will be benefited by small 
doses of thyroid, perhaps, coincidentally administered 
with small doses of iodid, as iodid has been shown to 
be the most active stimulant of the thyroid gland. 

TREATING THE PAROXYSM 

The best treatment of the paroxysm of asthma must 
be decided by a careful study of each individual pa- 
tient. There is no one best treatment for the asthmatic 
attack. The drug that most frequently is successful 
in rendering the patient comfortable and shortening 
the paroxysm is, of course, morphin, but before the 
physician begins the treatment of the asthmatic attacks 
with morphin he should have exhausted his other re- 
sources, as he is not sure that he can cure the asthma, 
even if he removes the reflex cause, and such patients 
readily acquire the morphin habit. If a given patient 
is incurable under the surroundings and conditions in 
which he must live and no other drug will relieve his 
suffering, he doubtless has the right to receive morphin, 
even if he does form the habit. 

In endeavoring to abort or shorten the attacks we 
may have recourse to the narcotics, which relieve the 
paroxysm by inhibiting the reflexes and dulling the re- 
ceptive centers. Such drugs are morphin, bromids, 
chloral, and chloroform by inhalation. 

We may use drugs that dull the peripheral nerves 
and prevent their susceptibility to the irritation from 
which they are suffering and thus abort the paroxysm. 
Such drugs are mostly of the atropin group, as bella- 
donna, stramonium and hyoscyamus. The effective 
action is atropin action, and doubtless atropin, and per- 
haps scopolamin (hyoscin) will do all the good that 
the crude drugs can do, although inhalation of the 
fumes from burning stramonium leaves has been 
used with success for centuries. 



230 TREATING PAROXYSM IN ASTHMA 

We may consider the treatment with such drugs as 
cause muscular relaxation by prostration. Such are 
emetics, and nicotin with patients who are not used to 
its action. 

The next group of drugs whose action we consider 
in the treatment of asthmatic attacks are vasodilators. 
These drugs not only dilate the peripheral blood vessels 
and therefore relieve congestion in the mucous mem- 
branes of the respiratory tract, but also are preventers 
of muscular spasm. Such are, of course, the nitrites 
in the form of amyl nitrite, sodium nitrite, and nitro- 
glycerin. The iodids will also cause lowered blood 
pressure, but are hardly of value during the attack. 

Many times quite the reverse of this dilating, relax- 
ing treatment is indicated in an asthma paroxysm. The 
vasoconstrictors are indicated, and if used in these in- 
stances will abort the attack. The best are solutions 
of epinephrin sprayed on the mucous membranes of 
the nostrils or throat, or into the larynx, or an epineph- 
rin preparation in tablet form may be dissolved and 
absorbed in the mouth. The action is of course im- 
mediate, and sometimes so is the relief. For the nos- 
trils epinephrin spray solutions of from 1 to 10,000 to 
1 to 5,000 (diluting with a mild alkaline solution) may 
be used. In the throat and larynx a strength of 1 to 
3,000 may be used. Digitalis is sometimes of advan- 
tage in these attacks even if there is no cardiac lesion 
or cardiac debility. Intramuscular injection of an 
aseptic preparation of ergot is also sometimes efficient 
treatment in stopping the paroxysm. 

Citrated caffein, or strong coffee, or strong decoc- 
tions of tea are of benefit during the asthmatic attack- 
in some individuals. The favorable action of caffein 
must be due to the cardiac stimulation and possibly to 
stimulation of the respiratory center. 

Strychnin given hypodermatically has been much rec- 
ommended for the asthmatic attack. While it generally 
fails, it sometimes does a great deal of good to patients 
who have bad heart action. A combination of strych- 
nin, morphin, and atropin given hypodermatically 
sometimes seems to act better than when die strychnin 
is omitted. 



INHALATIONS IN ASTHMA 231 

INHALATIONS 

Almost from ancient times paroxysms of asthma 
have been treated by the inhalation of fumes from 
burning medicinal substances. For this purpose the 
medicated substance may be in the form of cigarettes, 
powder, cones, or papers. Sometimes the fumes of 
these burning powders are directly inhaled, or the 
patient's bedroom is allowed to become filled with the 
fumes. Sometimes the attack is relieved by the inhala- 
tion of steam, or the vapor of boiling water in the 
room of the patient adds some relief. Sometimes 
liquid medicaments are added to boiling water in vari- 
ous apparatus for inhalation. Most popular, however, 
and most frequently used are the powders or papers, 
or pastils that are burned near the patient's face and 
inhaled directly. 

Probably nearly all the powders or papers ordered 
by physicians for inhalation for asthma and almost all 
of the patented preparations and nostrums contain 
niter (saltpeter) and stramonium, or belladonna, or 
other atropin-containing drug. The action of the niter, 
i.. e., potassium nitrate, fumes is to cause relaxation 
both of the blood vessels and of the bronchi. Papers 
are saturated with solutions of potassium nitrate, and 
when dry may be rolled in the form of a cigarette and 
smoked, or may be burned in any other form, and the 
fumes are beneficial to some patients. The addition of 
potassium nitrate to other medicinal powders causes 
them to burn more readily and give off their fumes. 

Stramonium (leaves) is the most frequent form in 
which the alkaloid atropin is administered by inhala- 
tion. The action of the atropin thus locally applied is 
to dull the irritability of the peripheral nerves in the 
nose, throat and larger bronchial tubes, and thus by 
relieving irritation tends to relieve spasm. At the 
same time the atropin acts as a circulatory stimulant. 

Various combinations of drugs are used for inhala- 
tion for asthmatics, many of which are nostrums (but 
have been analyzed) and have more or less efficiency 
in relieving the attack, because of the potent drugs 
often recklessly employed. The asthma nostrum ven- 
dor is looking mainly for immediate results, and he 
cares little w T hat the danger to the patient may be or 



232 ASTHMA CIGARETTES 

how strong a dose he gives ; consequently, he orders 
used sufficient amounts of the drugs to cut short the 
asthmatic attack. Therefore, the prescription which 
a physician is willing to write may not be so successful 
in a certain case as the nostrum temporarily may be. 

One form of asthma cigarette contains the following 
ingredients. 

Belladonna leaves 5 T /2 parts 

Hyoscyamus leaves 2% parts 

Stramonium leaves 2^4 parts 

Extract of opium y% part 

Cherry laurel water A sufficiency 

The dried leaves are cut small, mixed well, and 
moistened with the opium which has been dissolved in 
the cherry laurel water. A small amount of potassium 
nitrate is added in order that the cigarettes may burn 
readily. 

Arsenical cigarettes also have been used by asth- 
matics, sometimes beneficially. Yeo says that "these 
are made by dissolving 15 grains of arsenite of potash 
in half an ounce of distilled water and saturating un- 
sized paper with it. This is afterward dried, cut up 
into twenty pieces, each of which is rolled up into 
a cigarette. The smoke from the cigarette must be 
drawn into the bronchial tubes by a slow inspiration." 
It certainly is not obvious how arsenic can shorten an 
asthmatic attack. The administration of arsenic in 
small doses for some time may prevent the develop- 
ment of asthma, and chronic bronchitis is sometimes 
benefited by the prolonged use of arsenic. 

Oxygen inhalations have sometimes been used by 
asthmatics, and with relief. This, how r ever, is not 
very dissimilar to breathing the outside air, and will, 
of course, partly relieve the oxygen starvation. A 
patient who must go to the window and gasp for 
breath should, perhaps, have an oxygen tank in his 
room to use when he needs it. 

If we were to sum up the best treatment for the 
paroxysm of asthma we must say morphin and atropin 
hypodermatically, the administration of nitroglycerin 
by the mouth, cpinephrin into the nostrils or throat, 
or tablets containing cpinephrin dissolved in the 
mouth, fumigations with potassium nitrate and stra- 
monium, and cocain applications and sprays, if must be. 



HAY FEVER 

In this, as in most diseases, the aim is prevention, 
and before the periodic attack occurs, long before if 
possible, the patient's nose should be thoroughly exam- 
ined for localized irritations and hyperesthetic areas, 
and these should be cauterized or removed as deemed 
best by the nasal specialist. 

If, in spite of the building up of the general health 
and the local preventive measures, the attack of hay 
fever recurs, then before the date of the beginning of 
the disease the patient should if possible, go to a region 
where he has found that he is more or less immune. 
As the disease seems to be caused by the pollen or irri- 
tants in the atmosphere, produced or blown from vari- 
ous flowers and weeds, the ideal spot for these patients 
is one where there is little vegetation. Some patients 
do well in the mountains, some at the seashore, some 
on island resorts, some on sea trips. There generally 
can be found a region in which a patient is fairly im- 
mune, and to that he must resort annually. 

If the attack develops, sedative measures, cleansing 
measures and general systemic treatment must all be 
inaugurated. Simple cleansing alkaline sprays give 
some relief. Many patients are made better with weak 
solutions of suprarenal, perhaps 1 part to 10,000 of 
the active principle of suprarenal in physiologic salt 
solution, or in an alkaline solution such as the liquor 
antisepticus alkalinus, diluted with an equal part of 
water, or in Seiler's tablet solution, each tablet being 
dissolved in 30 c. c. (2 fluidounces) of water. Such 
a suprarenal solution may be used repeatedly. It 
causes no habit and will generally give temporary re- 
lief. In a few instances the reaction from its use 
causes more or less congestion, and in such cases of 
idiosyncrasy it should not be used. Sometimes an oint- 
ment of epinephrin hydrochlorid in a pure white vase- 
lin or petroleum (1 to a 1,000) is efficient in causing 
temporary relief. A drop or two of this is put into 
the nostril and the contraction of the mucous mem- 
brane from the absorption of the epinephrin is some- 
times as great as when suprarenal spray is used and 
often more lasting. Epinephrin tablets, containing 
0.002 gram, allowed to dissolve on the tongue, re- 



234 HAY FEVER 

lieve the congestion, especially in asthmatic cases, 
and will also relieve the asthma in these cases. Thin 
oil sprays containing adrenalin chlorid are also at times 
of value. 

There is no justification for the use of cocain as a 
spray or application if it is to be used frequently in 
hay fever or in any other nasal condition. The danger 
of forming the habit is too great. 

Antipyrin, quinin and various other local sprays 
have been recommended and used, but rarely are they 
of any aid in hay fever. 

The administration of various pollen preparations 
and pollen serums have been tried sufficiently to war- 
rant their recommendation, and occasionally a patient 
is benefited by such treatment. There have been many 
reports in recent medical literature regarding this 
method so that there seems to be reason for believing 
that when the correct pollen is found from which to 
make an extract, marked improvement may follow. 
Koessler (abstr. Jour. A. M. A., Sept. 5, 1914, p. 890) 
found marked improvement in 33 of 41 patients. Op- 
penheimer and Gottlieb (abstr. Jour. A.M. A., Feb. 20, 
1915, p. 697) found 4 patients benefited and five cured 
in a series of eleven active immunizations. 

Internally, the following drugs, although failing as 
many times as they benefit, should be tried in each case 
that is otherwise incurable, viz. : quinin, atropin, 
strychnin, antipyrin, iodids and thyroid. 

Quinin is sometimes of benefit in large doses, rarely 
in small doses. Its action when helpful is similar to 
that in certain cases of urticaria, perhaps as an anti- 
toxin. 

Atropin to be of value must ordinarily be given to 
the point of slight physiologic effect, such as dryness 
of the throat, increased rapidity of the heart, and 
flushing of the face. In susceptible individuals the 
pupils may also be dilated. The atropin treatment is 
certainly unpleasant, and minute doses are generally 
of little value. Occasionally a patient is benefited by 
1/300 or 1/400 of a grain three or four times a day. 
Such treatment should be tried until it is found value- 
K ss. 

Sometimes strychnin given in ordinary doses is of 
benefit. This is especially true in patients who are 



DRUGS IN HAY FEVER 235 

much weakened, and have a good deal of passive con- 
gestion or sluggish circulation in the mucous mem- 
branes. 

Antipyrin can only be of value when given in suffi- 
cient dose to act as an antispasmodic, much as it acts 
in whooping cough. It may possibly act as an anti- 
toxin to the irritant from the pollen, and may be of 
benefit when there are asthmatic symptoms. The dose 
for an adult to be of value, must be 0.50 gram (7y 2 
grains) three or four times in twenty-four hours. It 
is well to combine with this treatment the coincident 
administration of digitalis. If the condition is tedious 
and prolonged it would rarely be wise to give the anti- 
pyrin through the whole period of the disease. If 
patients suffering from this disease have weak acting 
hearts, digitalis may benefit them, unless they have 
some arteriosclerosis, in which case it is ordinarily 
better not to use it. 

In some patients iodids in small doses act for good 
in causing increased secretion and preventing some of 
the intense swelling of the mucous membranes. In 
other patients the condition is made rapidly worse. 
Sometimes a very small dose of an iodid, as 0.05 gram 
(or 1 grain) three times a day, after meals, or a small 
dose of thyroid as 0.05 gram (or 1 grain) of the of- 
ficial thyroid powder three times a day will increase 
the secretion, dilate other blood vessels and relieve the 
local congestion. This is especially true in asthma and 
hay fever after fifty, and where there is gout. 

Emmerich and Low (abstr. Jour. A. M. A., Jan. 17, 
1915, p. 247) report five cases in which a chronic ten- 
dency to hay fever was broken up and the patients 
permanently freed from its grip by continued treat- 
ment with calcium chlorid. The drug must be kept 
up for months, years, indefinitely, as it aims to remedy 
a constitutional defect — a disturbance, probably, in the 
functioning of the parathyroid bodies. They recom- 
mend all persons with a tendency to hay fever and 
even the healthy in regions poor in lime, or persons 
who do not take much milk or vegetables, to keep up 
the calcium chlorid indefinitely through years. Their 
experience of three and six years has confirmed, they 
say, the absolute harmlessness of the drug in the form 
advocated, while the general health is much improved, 



236 DIET IN HAY FEVER 

persons tire less readily, they require stimulants less, 
they sleep better, are less subject to infectious diseases, 
catarrhal affections, bronchitis, etc., the vital pro- 
cesses become less sluggish, and waste is thrown off 
more readily and completely. They add that Metch- 
nikoff's favorable results with yoghurt are probably 
due to the lime in the milk. The dosage they advocate 
is a teaspoonful of a 20 per cent, solution of crystal- 
lized calcium chlorid in distilled water, to be taken in 
a quarter of a glass of water in the course of the 
three principal meals. 

As in asthma, the diet should be very simple. Any 
extra gastrointestinal irritation will certainly intensify 
the hay fever symptoms. For the same reason the 
bowels should be thoroughly moved daily, perhaps best 
by a gentle saline, as phosphate of soda. 

Sometimes the hay fever manifestations are im- 
proved by treatment similar to that of uricacidemia, i. 
e., by a vegetable diet, one as free as possible from 
purin bases, and the administration of alkalies. The 
alkali may be potassium citrate or a similar drug. The 
benzoate of soda may be of value, and often small 
doses of effervescing Rochelle salt, as 1.00 gram (15 
grains) three or four times a day, are of benefit. 



DISEASES OF |THE GASTRO- 
INTESTINAL TRACT 



HYGIENE OF THE MOUTH AND TEETH 

The things to be remembered in the care of the 
mouth and teeth may be summed up as follows : 

1. Theoretically water should follow the milk of 
bottle-fed babies. 

2. A soft cloth should be thoroughly moistened with 
a mild alkaline wash and frequently applied over the 
first little teeth of the infant. 

3. No candy, or at least but little, should be given 
to young children, and as soon as their teeth have 
erupted they should have the more crunchy or granular 
cereals, and not so much of the soft, gelatinous cereals. 

4. The teeth should be regularly cleaned by a dentist, 
at least once in six months. 

5. All cavities, even small, should be filled, at least 
with temporary filling, so that the first teeth may be 
preserved as long as possible in order to develop the 
jaws properly, so that the second teeth need not be 
crowded. 

6. The teeth of children and adults should be thor- 
oughly brushed at least twice a day, better three times, 
with a proper brush, and, at least in the morning, with 
a tooth powder that is not too soapy, and at night with 
an alkaline mouth wash. 

7. All persons, growing children or adults, should 
have all the tartar that may become deposited cleaned 
from their teeth once in three months, and examina- 
tions of the teeth once in six months will disclose 
cavities before they have become large ones. 

8. If the teeth tend to degenerate and cavities 
quickly form, the trouble is generally with the nutri- 
tion, and the person is often deficient in bone-forming 
salts. vSuch patients should receive lime salts, phos- 
phates, glycerophosphates, and iron. 

The best iron preparations for this purpose are: 
tinctura ferri chloridi, 1 or 2 drops in a wineglass of 



238 HYGIENE OF THE MOUTH 

water or fresh lemonade, three times a day, after 
meals; ferrum reductum 0.05 gram (1 grain), in 
capsule, three times a day, after meals ; f erri oxidum 
saccharatum (Eisenzucker) , tablets, each 3 grains, 1 
three times a day, after meals. 

If the teeth are delayed in eruption and do not grow 
properly in young children, the dried extract of the 
thymus gland is of value. One of the tablets is given 
three times a day; it is best taken between meals, 
crushed with the teeth, and swallowed with water. 

If the child as a whole does not grow well, even if 
not a cretin or in any way like a cretin, small doses 
of thyroid extract (glandulse thyroideae siccae) in dose 
of 0.03 gram (J4 grain) once a day, is of value, and 
this dose is sufficient. 

In adults when the teeth tend to disintegrate 
perhaps the best treatment is the elixir of glycerophos- 
phates of lime and soda, and it is also well to admin- 
ister this preparation, or something similar, one or 
more times a day, to a pregnant woman, at least during 
the last months of pregnancy. 

9. The care of the mouth during severe illness 
should be on the lines above described. 

10. The proper care of the teeth will prevent Rigg's 
disease, one of the most troublesome and painful 
things that can happen to the jaws, meaning a retrac- 
tion of the gums and exposure of the dentine of the 
teeth ; proper care will also prevent that bane of older 
individuals, viz., pyorrhea alveolaris. 

11. The treatment of pyorrhea alveolaris must be 
strenuous and persistent. There is no excuse for its 
presence, and it can be eradicated. The treatment is 
persistent cleanliness and antisepsis, the same as in 
ozena. There is no excuse to-day for the horrible 
stench perpetrated by patients who suffer from ozena. 
The same is true of the nastiness of the breath of 
these pyorrhea patients, to say nothing of the danger 
to themselves of infection from germs harbored in the 
mouth. The treatment is a frequent use of a mouth 
wash of 1 part of peroxid of hydrogen solution to 4 or 
5 parts of warm water, and then the persistent use of 
an antiseptic alkaline mouth wash and tooth paste or 
tooth powder after the peroxid of hydrogen has eradi- 
cated and removed the pus. 






FOUL BREATH 239 

12. Before any serious operation is done abou^ the 
mouth, and when there is no emergency, the teeth of 
the patient should be cleansed, cavities at least tem- 
porarily filled, and pyorrhea alveolaris, if present, 
cured, or at least properly kept in subjection. 

FOUL BREATH 

It is rarely excusable for a person having once dis- 
covered that the breath is offensive to neglect its 
prevention. Perhaps the most frequent cause pertains 
to the teeth. There may be cavities, or there may 
simply be a lack of cleanliness from an insufficient use 
of the tooth brush and proper tooth powders, tooth 
pastes or mouth washes. It is also necessary to remove 
with a toothpick particles of food which may have 
become fixed between closely set teeth. All cavities 
should be filled and tartar deposits should be regularly 
removed, not only because of their likelihood to cause 
disagreeable odor to the breath, but of the possibility 
of allowing germs to develop and be swallowed. If 
the stomach is not in a healthy condition and the 
gastric juice not normal, such germs may not be killed. 
The proper tooth pow T der should be determined by the 
ease with which the teeth are cleaned, some requiring 
more friction in the powder, and others requiring more 
soap. The choice of the powder and the frequency 
with which the teeth should be brushed is determined 
by the results. They must be kept clean, and the 
cleaning must be done at least twice a day — in the 
morning and at bedtime. 

If there is any tendency to alveolitis, or if purulent 
alveolitis is present, then antiseptic, followed by alka- 
line, mouth washes should be frequently used until the 
condition is cured, but if it tends to recur, then such 
mouth washes should be used once a day, continuously. 
For a time weak peroxid of hydrogen solutions are 
beneficial, especially if the acid, which is formed after 
its oxidizing action, is quickly washed away with an 
alkaline solution. If gums are spongy a 5 per cent, 
solution of potassium chlorate makes an efficient mouth 
wash. One of the best local astringents and local anti- 
septics is a dilute solution (perhaps one part to five) 
of alcohol in water. 



240 MOUTH WASH 

The teeth not being the cause of the odor of the 
breath, the tonsils should be examined, and not infre- 
quently little calcareous deposits will be found in one 
or more crypts, or there may be a pocket of caseous 
deposit back of the tonsil. These should, of course, be 
removed and the crypts treated with some antiseptic 
solution and a cleansing antiseptic gargle given. 

Another frequent cause of bad breath is postnasal or 
nasopharyngeal catarrh. If this is a chronic condition 
the treatment is tedious, and unless the patient thor- 
oughly cooperates, results will be unsatisfactory. The 
proper treatment of nasal and nasopharyngeal catarrh 
can only be determined by a study of the individual 
condition. A warm cleansing solution is, of course, 
always important and the frequency of its use can only 
be determined by the rapidity with which the secretion 
forms deposits. 

In atrophic rhinitis the odor is terrible, and, un- 
fortunately, the condition is generally incurable; but 
there is absolutely no excuse for such a patient pol- 
luting the atmosphere of the rooms in which he works 
or lives. The odor can be prevented by the proper use 
of mild antiseptic and cleansing solutions, such as 
Dobell's solution. This solution is as follows : 



Gm. or c.c. 



m. xv 



aa gr. xlv 

A3 iiss 
ad A3 vii 



3 Phenolis 1 

Sodii bicarbonatis 3 

Sodii Boratis 3 

Glycerini 10 

Aquae, ad 200 

M. et Sig. : Use as an antiseptic gargle or as a nasal anti- 
septic spray. 

Other causes of disagreeable breath are constipation 
and dyspepsia. The cause of these conditions should 
be treated, and as the tongue becomes clean and the 
pharynx less congested the breath will become better. 

Laryngeal and bronchial inflammations and catarrhs, 
of course, are other causes of bad breath. I f the condi- 
tion is acute or subacute, it can soon be improved by 
proper treatment. If the condition is a chronic one, 
mild antiseptic inhalations will largely prevent the 
fetid condition. 



MOUTH WASHES AND GARGLES 241 

c.c. 

R Creasoti 1 1 m. xviii 

Olei pini silvestris 10 [ or A3 iii 

Tincturam benzoini com- 

positam, ad 100| ad A3 iv 

M. et Sig. : To inhale a teaspoonful from boiling water, 
one, two, or three times a day. 

MOUTH-WASHES AND GARGLES 

There are perhaps fifty mouth-washes on the market. 
They are all more or less similar in their composition, 
more or less multiple in their constituency, and more or 
less expensive, and represent more or less enormous 
profits to their owners. A number of pharmacopeial 
and National Formulary preparations have been devel- 
oped to meet the need for mouth-washes and also to 
imitate some of the proprietary preparations. 

Such polypharmacy as this is absolute nonsense. As 
in many pharmaceutical preparations, the value of the 
really useful ingredients is obscured by the useless 
shrubbery and weeds which surround them. A dash 
of this and a dash of that in these mouth-washes or 
gargles is simply playing to the galleries. Although it 
may seem a waste of time to criticize these simple and 
more or less harmless preparations, still, with the now 
recognized importance of oral cleanliness, it is as neces- 
sary to analyze our methods of procuring oral clean- 
liness as it is to note the efficiency of fumigation, and 
much of the latter is a delusion and a snare. 

As antiseptic for the mouth and throat we cannot 
improve on the carefully localized applications of the 
tincture of iodin or of weaker solutions of iodin ; when 
deemed advisable, of a strong solution of nitrate of 
silver carefully applied locally; or of local swabbing 
with strong hydrogen peroxid solution, or the more 
generalized washing or spraying with dilute solutions 
(provided that hydrogen peroxid is not applied to a 
deep ulcer or sinus where it can possibly cause disin- 
tegration of tissue). Strong preparations of glycerin 
and strong solutions of alcohol are other pleasant anti- 
septics, and the latter is decidedly astringent. 

When a strong antiseptic is used, after it has acted 
for a few minutes, soothing washes or sprays should be 
used. Also it should be remembered that any simple 
cleansing wash (than which perhaps nothing is better 



242 BORIC ACID IN MOUTH WASHES 

than simple salt solution in so-called physiologic 
strength, 0.9 per cent., or J4 teaspoonful of salt to 
about half a glass of warm water to which may or may 
not be added another y^ teaspoonful of sodium bicar- 
bonate) is of value on an inflamed mucous membrane. 
After such cleansing of the membrane, the antiseptic 
may be directly applied, if such is indicated, or the 
cleansing and soothing gargle or mouth- wash just men- 
tioned may be all that is needed. It is not the par- 
ticular preparation that is used, or the particular 
ingredients in mouth-washes and gargles, but it is 
efficient washing and gargling that is of benefit. 

The value of boric acid, not only in being mildly 
antiseptic, but also in promoting mucous secretion and 
therefore causing the easy removal of follicular exu- 
dates and membrane, should not be forgotten. Many 
times the insufflation of boric acid powder directly on 
the region involved is most efficient. At other times 
gargling of a solution in which boric acid is suspended 
is of value. While boric acid will dissolve in water 
only to about 4 per cent., a large surplus of boric acid 
should be left undissolved in the bottle. The bottle 
should be shaken, and the patient then gargles a boric 
acid solution which will deposit boric acid crystals on 
the throat, and will often be of as much value as 
though the powder were insufflated. 

Perhaps the most pleasing pungent taste to the 
majority of patients is peppermint, and there is no 
reason for mixing this up with several other aro- 
matics. If peppermint is disagreeable to a particular 
person, wintergreen may be substituted. 

The following are formulas of a few simple solu- 
tions for mouth and throat washes : 

Gm. or c.c. 

fy Acidi borici 2\ 3 ss 

Potassii chloratis 5| or 3i 

Aquae menthae piperitae 200] fl5 vi 

M. Sig. : Use as a gargle or mouth-wash, diluted or undi- 
luted, as directed. 

Gm. or c.c. 

fy Sodii chloridi 

Sodii boratis aa 2 3 ss 

Glycerini 50 or AS iss 

Aquae gaultheriae. ..q. s. ad 200 rlSvi 

M. Sig.: Use as a gargle or mouth-wash, diluted or undi- 
luted, as directed. 



ALCOHOL IN MOUTH WASHES 243 

Gm. or c.c. 

I£ Acidi salicylici 2| gr. xxv 

Glycerini 25 1 or A3 v 

Aquae menthae piperitae, 

q. s. ad 200 1 flgvi 

M. Sig. : Use as a gargle or mouth-wash, diluted or undi- 
luted, as directed. 

The value of dilute alcohol washes, such as one part 
of alcohol to four or five parts of water, should not 
be forgotten. Alcohol is astringent, cleansing and 
antiseptic. Sometimes potassium chlorate solutions, 
though very disagreeable, are most healing when the 
whole mucous membrane of the mouth is more or 
less inflamed. If there are no pockets in which hydro- 
gen peroxide may form bubbles and cause an exten- 
sion of ulceration, there is no mouth-wash more 
antiseptic and more efficient than diluted hydrogen 
peroxid solution, as one part of hydrogen peroxid 
solution to three or four parts of warm water. 
Immediately after the use of hydrogen peroxid solu- 
tions a mild alkaline solution should be used to wash 
off the froth caused by the peroxid action and also to 
remove the acid irritation caused by such action. 

If the mouth is dry during illness, some slightly 
pungent substance may be taken, to be either chewed 
or swallowed, such as some effervescing water, ginger 
ale, some pungent mint chewing-gum, or even a simple 
peppermint lozenge. Of course the value, in such 
conditions, of vegetable sours such as lemonade, 
orangeade or a piece of orange is well understood. 
These will increase the mouth secretions and prevent 
drying of the mucous membrane, which is such a 
frequent cause of ulceration. 

Various preparations of glycerin diluted with water, 
with or without boric acid or borax, or boroglycerid, 
or milk of magnesia, are all valuable in preventing or 
aiding in the healing of a sore mouth. 

If the tincture of iodin does not heal an ulcer or 
fissure, one or two applications of either the stick 
nitrate of silver or a 25 per cent, solution, applied by 
means of a swab, will generally cause healing. 

If the patient is too ill for strenuous or perfect 
cleanliness of the mouth, as soon as convalesence is 



244 CARE OF THE TEETH 

established extra care should be given the mouth and 
teeth. 

It should not be considered that a patient has been 
thoroughly examined until the condition of the mouth 
has been investigated. As before stated, too many 
chronic diseases have their source and continuation 
from diseases of the gums or from neglected, decayed 
teeth, to say nothing of diseased tonsils. A fetid, bad 
breath should always be investigated, as it is generally 
due to a chronic inflammation in the mouth. While a 
large portion of adults over 40 have more or less 
pyorrhea alveolaris, a large number of these patients 
may have the condition entirely prevented, and by 
various methods to-day many patients are cured of 
what was long considered an incurable condition. 

The foregoing of course are only suggestions, and 
each physician should order the mouth-wash that he 
desires for his patient as carefully as he would write 
any other prescription. There is nothing wonderful 
or mysteriously curative in any of the formulas 
described, and simple home remedies will often be as 
effective as an expensive proprietary preparation, 
unless an antiseptic is required. Even simple starch 
water makes a very soothing gargle. 

It is not our object to discuss the value of the vari- 
ous proprietary tooth-pastes. That the use of an 
antiseptic tooth-paste or an antiseptic mouth-wash, 
once or twice a day, will prevent acute infections that 
more or less enter through the nostrils must of course 
be denied. Strong antiseptic tooth-paste will not be 
tolerated by most gums, and it has been suggested 
above that one does not want the tooth-cleansing prep- 
aration too soapy, too irritant or too harsh. 

If there is actual inflammation of the gums, medical 
or dental advice should be sought. 

CARE OF THE TEETH 
It has too long been believed that a serious illness 
caused of itself .degeneration of the teeth, either cavi- 
tation or actual loss. While there are many of the 
elements of nutrition that are needed for the teeth to 
remain healthy, neglect of the mouth and teeth is 
probably the larger factor in their defeneration. 
Tartar forms, inflammation begins and pus-pockets 



CLEANSING THE TEETH 245 

develop around the teeth when they are not properly 
cleansed and the gums are not properly cared for. 

If the patient is so ill that he cannot allow brushing 
of the teeth either by himself or by the nurse, the 
gums and teeth should be cleansed by rubbing or 
spraying with the liquids selected. A great source of 
cleanliness for the teeth is chewing, which is more or 
less in abeyance during serious sickness, but we are 
learning that in most of the prolonged acute diseases 
the patient is able and willing to chew such simple 
thing as dry toast. This alone cleanses the teeth, 
starts the saliva and normal mucous flow, and fre- 
quently offers a better food than the constant swallow- 
ing of even nutritious liquids. If the ordinary simple 
cleansing lotions are not sufficient to prevent the 
formation of pus or ulcerations, various applications 
to the regions of trouble should be made, and perhaps 
none is better than the tincture of iodin, or, if that 
is considered too severe, a modified solution of iodin 
as follows : 

Gm. or c.c. 

B Iodi II gr. xv 

Potassii iodidi. 3| or gr. xlv 

Glycerini 30] A3 i 

M. Sig. : Use externally as directed. 

Gies (Household Arts Review, May 1913, p. 12) 
has found that so-called antiseptic mouth-washes and 
alkaline washes do not wash off or dissolve this adher- 
ent mucin, and therefore are not effective in prevent- 
ing decay of the teeth. He quotes Pickerill and a 
discussion in the New York Academy of Medicine 
(Jour. Allied Dental Soc, 1912, VII, 397) and Dr. 
Howe and records his own investigations to show 
that the vegetable acids, such as diluted vinegar and 
the fruit juices and their acids, are the most successful 
cleansing substances that can be used on the teeth. 
These investigators all state that a diluted vinegar is 
perfectly successful as a cleanser of the teeth. They 
also believe that starches and sugars should never be 
eaten alone, but should be certainly followed by some 
acid substance, as some of the acid fruits or some of 
the vegetable sours. After most meals, therefore, it 
is good sense to eat a little fruit, and on going to bed 



246 PYORRHEA 

perhaps the most successful cleanser of the teeth is 
a little sour fruit or diluted fruit vinegar. 

Children and patients should also be taught to brush 
the gums as well as the teeth, and when it is needed a 
patient should be taught to massage the gums. The 
use of wooden toothpicks to remove particles between 
the teeth that cannot be removed by the tooth-brush 
should be approved. 

Many patients' teeth are so close together that par- 
ticles of food remain lodged between them and cannot 
be removed in any other way. Dental floss should 
certainly be used occasionally, or frequently, if pos- 
sible. If inflammation actually occurs in the gums or 
around a tooth, the advice and care of a dentist are 
needed. 

PYORRHEA ALVEOLARIS 

Recent investigation appears to have demonstrated 
that Endameba buccalis stands in some etiologic rela- 
tion to pyorrhea either as a germ invading the space 
between the gum and the teeth and causing the con- 
dition known as pyorrhea alveolaris, or playing a sec- 
ondary role invading a cavity already formed as a 
commensual parasite and greatly aggravating the 
existing condition. It has further been shown that 
ipecac and its alkaloid, emetin, exercise a specific 
influence over the Endameba buccalis, which disap- 
pears promptly from the alveolar pus pockets when 
emetin is given hypodermically. The destruction of 
the endameba is only temporary, however. Reinfec- 
tion occurs not infrequently at the end of ten to 
fourteen days. Prophylaxis of pyorrhea is to be 
distinguished from the prophylaxis of the degenera- 
tion of the alveolar process known as interstitial 
gingivitis which is due to constitutional causes. 
Whether this separation of the gums from the teeth 
has occurred or not cleanliness of the gums and teeth 
especially at the gum margin should be carefully 
observed. 

The employment of iodin on the gums is both anti- 
septic and stimulating to the tissue of the gums which 
becomes firmer under its use. Talbot describes this 
use of iodin as follows: A mixture which he calls 
iodoglycerol consisting of zinc iodid, 15, water, 10, 



EXAMINATION OF STOMACH CONTENTS 247 

iodin, 25 and glycerin, 50 is applied with cotton wound 
around wooden applicators to the gum margins above 
and below. The lips and cheeks are held away from 
the jaws until the iodin has dried. These applications 
should be made every day and continued until the 
patient is dismissed. 

The treatment of pyorrhea consists first in the 
removal of tartar which, accumulating between the 
gums and the teeth, separates the two and presents 
a cavity for the invasion of germs. Solution of per- 
oxid of hydrogen may be used as a mouth wash. 

The demonstrable endamebas can be destroyed by 
giving y 2 grain of emetin hydrochlorid hypodermically 
for three to six successive days. Apparently equal 
endamebacidal effect is produced by two or three 
Alcresta ipecac tablets (Lilly) taken by mouth three 
times a day for four to six successive days. The 
lesions require variable lengths of time to heal, but 
many could not reasonably be expected to heal in less 
than several weeks or months. The treatment must 
be repeated from time to time until the lesions all 
heal, on account of relapse, or probably reinfection 
of the lesions as a result of the great prevalence of the 
infection. Injecting ipecac or emetin into the worst 
lesions ought to be of service and can be carried out 
by patients in many instances. Rinsing the mouth 
thoroughly with a solution of fluidextract of ipecac is 
believed to protect, to some extent, against reinfection, 
and may cure the disease in its earliest stage in some 
instances. 

The importance of adequate dental assistance in 
pyorrhea cannot be overestimated. 

THE EXAMINATION OF STOMACH CONTENTS 

Test Meal. — The object of the test meal is to show 
the state of digestion. For this purpose a meal con- 
sisting of ordinary food is most appropriate. It has 
recently been suggested that gastric secretion is suf- 
ficiently stimulated by ordinary water and in this way 
the gastric juice can be secured in a state of great 
purity, especially fit for chemical examination. While 
this is true such a meal does not indicate how the 
stomach deals with ordinary food. For the latter 
purpose the test breakfast of Ewald has long been 



248 REMOVAL OF STOMACH CONTENTS 

used and has proved itself very serviceable. It should 
be used as a routine. It consists of bread and tea or 
bread and water. The amount of bread should be 
from 35 to SO gm. No butter, sugar, milk or spices 
are used. The amount of bread can be supplied by 
two slices of bread, a roll, or five ordinary soda crack- 
ers. The amount of tea should be two ordinary cups 
approximating 400 c.c. or a pint. 

The meal should be taken on an empty stomach, 
before breakfast or in place of the noon meal. The 
latter time has the advantage that in case of motor 
insufficiency remains of the breakfast may be found 
in the stomach contents. In this case it is well for 
the patient to eat some article of food for breakfast 
that can be easily recognized. The test meal should 
be tastefully prepared and tastefully served. Such 
table accessories should be furnished as will make 
it as attractive as possible. Preparations for the 
removal of the contents should be made without 
attracting the attention of the patient. The time for 
removing the contents should be reckoned at one hour 
from the time of beginning the meal. 

In some cases this time may prove too long because 
the lack of acid permits the contents to leave the 
stomach prematurely and no contents are brought back 
through the tube. In such a case the meal should be 
given again and the contents removed at the end of 
forty-five minutes or even a half hour. 

Removal of Stomach Contents. — The technic of re- 
moving stomach contents is simple. The patient should 
be covered with an apron to protect the clothing; the 
physician may also find it advantageous to wear a 
gown. A shallow basin should be provided to re- 
ceive the contents ; a better arrangement is a stout 
glass jar known as a celery jar which should be placed 
in a larger basin. It is well to suggest to the patient 
to hold the basin with his hands. This serves to keep 
the hands occupied and tends to lessen the tendency 
of the patient to pull out the tube. The patient should 
be assured that the operation will not hurt; at the 
same time it is best to admit that it will be disagree- 
able and especially thai it is apt to give a sensation of 
difficulty, in breathing, but that this will disappear if 
the patient breathes regularly through the nose. The 



EXAMINATION OF STOMACH CONTENTS 249 

tube to be used is a simple tube with one lateral 
opening and one at the end. To the upper end a short 
piece of rubber tubing is attached by a connecting 
short piece of glass tubing and the shorter tubing is 
attached by a piece of hard rubber to a strong walled 
bag like a Pollitzer bag. This serves as an aspirator 
to remove the contents by suction. 

The tube is introduced by the hand of the operator 
holding it like a pen. It is not necessary for the hand 
to enter the mouth. The operator should stand partly 
behind the patient and may steady the patient's head 
with the left hand. When the tube has entered the 
stomach the contents may flow spontaneously; if not 
the flow may be stimulated by moving the tube up 
and down which excites some nausea. If the contents 
are not easily obtained the aspirator should be emptied 
of air and attached. When it is allowed to expand 
the contents will flow into the bag and can be emptied 
into the receptacle provided. The temptation will 
sometimes arise to facilitate the removal of contents 
by injecting water. This defeats the object of the 
removal as the contents obtained is practically worth- 
less even for qualitative tests. At the termination of 
the process the patient should be warned against 
spitting in the dish containing the contents. He may 
spit in the outer basin. 

Examination. — The stomach contents should be 
measured. The contents ordinarily secured varies 
from fifty to one hundred and fifty cubic centimeters ; 
a quantity above 150 c.c. is indicative of one of two 
things : either there has been a retention of food rem- 
nants on account of motor insufficiency or a hyper- 
secretion of the gastric juice has occurred. The chemi- 
cal examination will usually determine this question. 

The macroscopic examination of stomach contents 
is perhaps of more importance than the laboratory 
investigation. For this reason the physician should 
remove the contents himself. The contents should 
be poured into a clean basin and poured back again 
into the original dish. The color should be noted. A 
greenish color may indicate admixture with bile; it is 
also sometimes due to a growth of mold or other 
fungi. Mucus will be recognized by the stringiness 



250 CHEM. EXAM. OF STOMACH CONTENTS 

of the contents which is readily seen as the liquid is 
poured from one vessel to the other. Mucus may be 
swallowed from the throat or possibly from the chest. 
Such mucus is light and frothy, or in lumps which 
float on the surface; stomach mucus clings to the 
vessel and is intimately mixed with the other contents. 
Blood may be readily recognized, but is of minor sig- 
nificance; it is frequently shed by the mucosa which 
has been injured by the tube. The mucosa is espe- 
cially liable to suffer such injury in achylia gastrica. 
The condition of digestion is easily observed by the 
appearance of the remnants of the roll. If digestion 
is good the gluten of the flour is digested and the 
starch sinks to the bottom as a fine sediment. If the 
digestion is imperfect the roll is coherent and in case 
of total lack of acid the bread appears as if it had just 
been swallowed or it may be enveloped in glairy mucus. 
Occasionally small pieces of mucous membrane will be 
found which have been stripped ofif by the tube. 

Having noted these striking characters one should 
proceed to the chemical examination. Usually it is 
not necessary to filter the contents. A piece of congo 
paper may be dipped into the contents ; if free acid is 
present the red paper changes to blue. A piece of 
tropeolin paper will turn brown if free hydrochloric 
acid is present and on drying this at a gentle heat the 
color will change to a violet. This is usually sufficient 
to demonstrate the digestive power of the mixture. 
One proceeds at once to the titration of acids for which 
a determination of the free hydrochloric acid and the 
total acidity are sufficient for routine examinations. 
10 c.c. of the contents are measured, most conveniently 
in a 10 c.c. graduated cylinder and poured into a small 
beaker glass. It is well before reading the amount 
in the cylinder to remove any mucus floating on the 
top by means of a pair of small forceps and fill up to 
the mark with clear fluid. After emptying the cylinder 
it may be rinsed with distilled water and the rinsings 
added to the fluid in the beaker. This is then titrated 
for free HC1 by running in from a burette decinormal 
sodium hydroxid solution with dimethyl-amino-azo- 
benzene as an indicator until the red liquid becomes 
orange yellow (not lemon yellow). The reading of 
the burette is then taken and one or two drops of 



EXAMINATION OF FECES 251 

solution of phenolphthalein are added to the liquid in 
the beaker. The alkali solution is then run in until 
the liquid shows a distinct tinge of pink after stirring. 
This gives the total acidity; both readings are taken 
from the zero point and the figures multiplied by ten 
to get the amount of alkali required to neutralize acid 
in 100 c.c. of stomach contents. These figures are 
customarily used in reports and are designated as the 
degree of free and total acidity. 

The tests described above consume little time (not 
more than fifteen minutes for one accustomed to the 
work) and may suffice for the examination in the 
majority of cases. Some other tests ordinarily des- 
cribed, are not needed in ordinary clinical work 
because their results can be predicted from the results 
of tests already made. Among these may be included 
the following. Tests for the digestive action of the 
saliva are unnecessary because we may assume with 
fair certainty that starch digestion will be poor in the 
presence of high acidity, fair with normal acidity, and 
very good with low acidity. Tests for the presence 
of pepsin are unnecessary unless there h no free 
hydrochloric acid. In the absence of hydrochloric acid 
the presence and amount of pepsin should be tested 
for. Tests for lactic acid are quite unnecessary when 
there is free hydrochloric acid. When hydrochloric 
acid is very deficient or absent lactic acid should be 
tested for. If the total acidity is as low as 8 the 
probability of achylia gastrica may be assumed. 

Microscopic Examination. — For examination with 
the microscope a drop of the contents is placed on a 
slide and examined with a low power. It can advan- 
tageously be stained with a weak Lugol's solution. 
Starch is colored blue, proteins yellow, and some bac- 
teria blue. The objects of interest are Oppler-Boas 
bacilli, long bacilli often bent on themselves, sarcinae 
masses of cocci aggregated in groups of eight with 
divisions between the individual cocci which cause the 
mass to look like a fleece of wool, yeast cells and starch 
granules. 

EXAMINATION OF FECES 

The examination of feces is of little value so far as 
the diagnosis of indigestion is concerned unless a 
definite diet is prescribed so that one may know what 



252 MICROSCOPIC EXAMINATION OF FECES 

appearances the residues of the food should present 
under normal conditions. The original test diet of 
Schmidt was devised so as to conform to German 
dietetic customs and is ill adapted to American habits. 
Several modifications of this diet have been proposed 
among them the following menu by Dr. M. M. Scar- 
borough. 

Breakfast: — One soft boiled egg, 2 slices of toast 
with butter, 1 bowl of oat-meal w T ith sugar and cream, 
1 glass of milk, and 1 cup of coffee. If coffee is not 
desired, another glass of milk may be substituted. 

Dinner : — A quarter pound of finely chopped round 
steak (very slightly broiled so that most of it is rare) 
y 2 pound of mashed potato, 2 slices of white bread or 
toast, plenty of butter, and 1 or 2 glasses of milk. 

Supper : — Same as the breakfast. 

A patient is put rigidly on the above diet for three 
or four days. At the beginning of the diet he is given 
a tablet or capsule containing 0.30 gram (5 grains) of 
pure willow charcoal. This dose of charcoal is re- 
peated at the end of the diet. The consequent black 
stools from these two doses of charcoal will mark the 
beginning and end of the period of special diet. The 
length of time it takes the charcoal to go through the 
intestines will determine their activity and whether 
the food is delayed or not in its passage through the 
alimentary tract. The second dose of charcoal is use- 
ful only to determine whether the activity of the canal 
has changed during the rigid diet. The stool which 
is to be taken for examination should be at the end of 
the third 24-hour period of the diet and before the 
administration of the second dose of charcoal. The 
stool desired may be collected in a wide mouthed jar 
or what is more convenient for the ordinary examina- 
tion, a sample may be transferred to a glass ointment 
jar and transmitted to the laboratory for examination. 
The examination may be divided into macroscopic, 
microscopic and chemical. 

Macroscopic Examination. — Macroscopically, under 
normal conditions, we find a soft-formed stool, light- 
brown in color and of uniform consistency. A liquid 
stool usually denotes a too rapid passage of food 
through the tract ; a tarry stool indicates blood coming 



MICROSCOPIC EXAMINATION OF FECES 253 

from the stomach or high up in the intestine. Flakes 
of mucus, blood, pus, etc., are pathologic. Next a piece 
of feces the size of a walnut is ground up in a mortar 
with a little water and then spread out on a glass plate 
in a thin layer. The plate should be placed over a 
sheet of paper half of which is white and half black. 
The normal feces appear perfectly homogeneous ex- 
cept for here and there small broken, brownish points 
of cellulose from the oatmeal eaten. In this prepara- 
tion may be seen food remains which are abnormal. 
Firm whitish or yellowish strings of connective tissue, 
and small brown-colored rods of muscle fibre, appear- 
ing like splinters of wood, may be seen here and there, 
denoting improper indigestion of the meats. Starch 
granules in the form of glassy transparent globules 
like sago grains, may be present and must be distin- 
guished from shiny, ragged flakes of mucus. 

Microscopic Examination. — The microscopic exam- 
ination is very simple. A small. mass of feces is 
pressed out in a thin layer on a slide by means of a 
cover glass. A little water may be added if necessary. 
Normal excrement from the test-diet appears as a fine 
detritus of granules, globules and bacteria interspersed 
here and there with fragments of muscle fibers, small, 
irregular, yellowish flakes of calcium salts and less 
numerous skeletal remains of potato cells, besides the 
chaffy particles from the oatmeal. On a second slide 
a small piece of feces is stirred up with two drops of 
a 35 per cent, solution of acetic acid, heated over a 
flame until bubbles arise, and then set to cool. The 
process causes a liberation of the free fatty acids which 
flock out on the surface of the preparation, giving a 
rough index to the amount of fat in the stool. 

On a third slide an iodin solution (liquor iodi com- 
positus, Lugol's solution, diluted with equal part of 
water is used, which stains the starch, yeast and 
other fungi that may be present. The microscopic 
examination may reveal the following pathologic com- 
ponents : fragments of muscle fibres large in size and 
in good state of preservation; clusters of undigested 
starch grains ; numerous needles and crystals of fatty 
acids and soaps ; and occasionally various fungi. 



254 PATHOLOGIC FINDINGS IN FECES 

Chemical Examination. — The chemical tests are very 
simple. The litmus reaction is taken; normal stools 
are faintly alkaline or at least feebly acid. Next a 
little of the stool is mixed with a strong bichlorid 
solution (a saturated solution of corrosive sublimate 
in water, which is, in cold water, not far from 7 per 
cent.) ; normal feces give a red reaction, while feces 
that have passed through the tract so rapidly that the 
bile has not been reduced give a greenish color. The 
greenish color is abnormal and shows that unchanged 
bile pigments have passed entirely through the intes- 
tinal tract. The last test is the amount of gas that 
the stool will give off. An acid stool with an excess 
of carbohydrates will ferment if kept warm and give 
off considerable carbon dioxid; on the other hand a 
stool which gives an alkaline reaction and contains 
much unabsorbed protein will readily undergo putre- 
faction and evolve ammonia and hydrogen sulphid. 
The gas from decomposing feces can be collected by 
filling a large test tube with diluted feces and invert- 
ing the tube over water in a shallow dish and placing 
in an incubator for a day or two. 

Pathologic Findings. — The significance of pathologic 
findings are briefly as follows : 

Mucus in the stool means inflammation of the colon 
or rectum. Rarely it may come from the small intes- 
tine. A green color with the bichlorid test indicates 
a very rapid passage of intestinal contents. Absence 
of bile pigment denotes complete obstruction of the 
biliary duct. The pigment may be obscured by excess 
of fat, which should be removed by ether before a 
final opinion as to the absence of biliary pigments 
should be expressed. 

The finding of meat remains is of great significance. 
Connective tissue never appears in the feces after the 
test-diet unless there is disturbance of digestion in 
the stomach, a diminished gastric juice. Muscle fibers 
are not digested in the stomach, but in the intestine. 
Even in complete achylia gastrica the muscle fibers 
may be completely digested leaving the connective 
tissue skeleton of the meat unaffected. The presence 
of muscle fibres in a good state of preservation always 
means trouble in the small intestine, due to one or 



DIAGNOSIS FROM FINDINGS IN FECES 255 

more of the following conditions : the pancreatic juice 
may be insufficient; or the active enterokinase of the 
secretions of the small intestine may be absent; or 
finally, there may be a marked hypermotility, too rapid 
peristalsis, of the small intestine, thus not allowing 
time for digestion of these elements. A method for 
the investigation of the exact cause of intestinal indi- 
gestion of meat fibers has not yet been satisfactorily 
worked out. However, as the nuclei of tissue cells are 
digested only by the pancreatic secretion, Schmidt has 
devised his nuclei test which consists in giving a small 
cube of meat placed in a small porous silk bag. The 
bag almost always contains remains of the tissue after 
passing through the gastro-intestinal tract. If undi- 
gested nuclei are present, it is safe to conclude that 
there is an unsatisfactory functioning of the pancreas. 

The presence of starch elements indicates its incom- 
plete digestion in the small intestine and shows a dis- 
turbance of the pancreatic secretion and of the intes- 
tinal juice. Insufficiency of starch digestion is further 
confirmed by the fermentation test and by the finding 
in the stool of organisms that stain blue or violet with 
iodin. 

In the feces of constipated persons, as a rule, there 
are few food remnants, few bacteria, and water has 
been largely absorbed rendering the feces dry and hard. 
Digestion in the constipated may be said to be too 
good. 

DIAGNOSIS AND TREATMENT 

The diagnostic findings and the indications for treat- 
ment may be summed up as follows : 

1. If the charcoal is slow in passing through the 
alimentary canal, i. e., more than thirty-six hours after 
ingestion, intestinal peristalsis is sluggish. 

2. If the fecal matters are very dry, there is too 
great absorption of liquid from the intestines. 

3. If the stools are very liquid, there is generally 
too rapid peristalsis. 

4. If the fecal matters are distinctly or very acid, 
there is an imperfect intestinal digestion. 

5. If there is much gas in the feces, there is maldi- 
gestion of some kind; it may be purin maldigestion 
or carbohydrate maldigestion. Whichever it is other- 



256 PATHOLOGIC OVA IN FECES 

wise determined that it is, that particular kind of food 
should be limited. 

6. If there is undigested connective tissue found 
microscopically, the trouble lies in the stomach, which 
should then be studied by means of the test breakfast 
and examination of the stomach contents withdrawn 
an hour after the test breakfast has been taken. If 
there are undigested muscle fibers present, there is in- 
sufficient pancreatic secretion, and meat should be 
diminished or temporarily withdrawn from the diet. 

7. If there is a large amount of undigested starch 
particles, the pancreatic juice is deficient, at least in its 
starch digestion properties ; consequently the starch in 
the diet should be diminished. 

8. If the bile pigments are absent, of couse the bile 
is not secreted (or excreted) into the alimentary tract. 
If there is a large amount of fatty acids, or if there 
is a large amount of fat in the stool, it shows 
deficient bile secretion, and the amount of fat ingested 
should be greatly diminished. 

9. Abnormal bacteria, or an abnormal amount of 
bacteria, or specific bacteria would suggest various 
diets, bowel antiseptics, purgings, and various syste- 
mic treatments, depending on the findings. 

10. Much mucus or pus would suggest the treat- 
ment, depending on the region from which it was sup- 
posed to come ; colon washings or colon treatments, 
if the colon was at fault. 

11. If there is blood in the stool, evident or occult, 
it must be determined, if possible, from what part of 
the tract it comes. 

THE FINDING OF PATHOLOGIC OVA 

Fauntleroy and Hayden (Abstr. Jour. A. M. A., 
Feb. 13, 1915, p. 620) have devised a method 
which consists essentially of staining the fecal matter 
with anilin gentian violet. This solution stains every- 
thing on the slide except the eggs. It does not 
penetrate the membrane about the eggs and they are 
there fore left in a natural state. None of the other 
ordinary colored stains will do this. The entire slide 
with the exception of the real eggs is stained violet. 
This method of examination has been usvd in the exam- 



INTERPRETATION OF GASTRIC SYMPTOMS 257 

ination of over a thousand stools with uniform success. 
All eggs, hook-worm and others, stand out very clearly 
and beautifully. About 2 gm. of the fecal material 
are thoroughly mixed with 5 c.c of a 2 per cent, aque- 
ous solution of compound solution of cresol in a cen- 
trifuge tube. The specimens are centrifugalized at 
high speed for one minute, the supernatant liquid is 
then decanted and fresh compound cresol solution 
added and mixed with the sediment in the tubes. This 
operation is repeated three times. On completion of 
the centrifugalization process a small portion of the 
bottom sediment is removed with a clean pipette and 
placed on a clean slide, a small drop of anilin gentian 
violet mixed with the sediment, and a clean cover- 
glass placed on it. 

INTERPRETATION OF SYMPTOMS REFERABLE 
TO THE STOMACH 

There is perhaps no group of symptoms regarding 
which there is more misapprehension among physi- 
cians than symptoms arising from the stomach or felt 
in the region of the stomach. 

INDIGESTION 

Indigestion is a much abused term commonly used 
to cover all forms of stomach disease. Strictly it 
means the non-digestion of food. This is a rare event 
among those who are not seriously ill. That digestion 
may fail in the stomach or in some other part of the 
alimentary canal or that some parts of the food may 
escape digestion is common enough, but the human 
organism is provided with compensating mechanisms 
so that if one organ in the digestive system fails to 
perform its duty another is usually capable of taking 
its place. As a rule in adults, even in the case of 
those who complain of trouble with the stomach or 
bowels, only a minimum of the food ingested escapes 
digestion or fails to be absorbed. The test of diges- 
tion is found in the state of the bowels ; if the bowels 
act normally or are constipated as a rule the digestion 
is complete and may indeed be too good. If there is 
diarrhea it may be assumed that digestion is imperfect, 
although there may be no lesion of the stomach or 



258 RELATIONS OF STOMACH 

intestines. We may repeat that indigestion is not a 
common symptoms in the ordinary chronic affections 
of the stomach and intestines. As a corollary of the 
above we may affirm that digestive ferments are not 
often lacking and there is rarely a rational indication 
for prescribing artificial ferments to supply a lack 
in the normal action of these organs. Such drugs 
should be prescribed only after their deficiency has 
been shown by the proper tests. 

THE IMPORTANCE OF STOMACH DIGESTION 

It is not desirable to over-rate the importance of 
the processes going on in the stomach in the final 
process of digestion. The stomach is a preparatory 
digestive organ. It is a reservoir which reduces the 
food to a fine state of subdivision and renders it suit- 
able for the subsequent action of the secretions of 
the liver, pancreas, and intestines. Its work is seldom 
complete. The organ may be removed or fail to 
perform its functions without any serious disturbance 
in nutrition. Nevertheless one cannot deny that 
changes in the utilization of food may occur in the 
absence of the correct function of the stomach which, 
in the long run, may seriously affect metabolism and 
nutrition. In this connection we may note some 
peculiarities of the motor action of the stomach which 
have important bearings on treatment. The stomach 
does not absorb water and hence in case a liquid 
which needs no digestion is taken, even at meal time, 
a special channel is formed along the lesser curvature 
by which the liquid is conveyed to the intestine with- 
out mingling with more solid undigested contents 
of the stomach. The taking of liquids at meal time 
does not, therefore, dilute the gastric juice as was 
formerly taught. Such an event may happen, how- 
ever, when the stomach is atonic and allows water 
or other liquid to flow into the lower part instead 
of conducting it into the intestine in a normal manner. 

RELATION OF THE STOMACH TO OTHER ORGANS 

It should always be borne in mind that the stomach 
has important nervous connections with other organs 
by which it reflects like a mirror events taking place 
in other parts of the digestive system. Symptoms 



FUNCTIONAL GASTRIC DISTURBANCES 259 

apparently arising in the stomach may, in reality, 
depend on disease of the liver, gall-bladder, appendix, 
or lower bowel. Neighboring organs not connected 
with the process of digestion or even remote organs 
may produce a reflex disturbance in the stomach. A 
very large part of the disturbances of the stomach 
are of psychic origin. The physician should always 
interpret the symptoms presented by the patient who 
thinks there is something wrong with his stomach in 
the light of possible disease of other organs or of 
mental disturbances. Even in the presence of proved 
organic disease the possible influence of emotion in 
producing symptoms should not be forgotten. 

THE MAJORITY OF STOMACH CASES FUNCTIONAL 

While the existence of serious organic disease 
should never be overlooked it is well to understand 
that only a small proportion of patients who come 
to the physician complaining of the stomach or of 
digestive disturbances have ulcer or cancer. The 
physician should not make or suggest a diagnosis of 
serious disease until he has proved its existence by 
appropriate physical and laboratory examinations. 

SYMPTOMS NOT CHARACTERISTIC 

Diagnosis on the basis of the patient's recital of 
symptoms without physical examination or the anal- 
ysis of a test-meal or of the feces is much too 
common. It may be said at the outset that there 
exists scarcely a symptom that is characteristic of any 
definite stomach disease. This may explain the readi- 
ness with which practitioners resort to such terms as 
indigestion, dyspepsia, catarrh of the stomach or the 
indefinite term "stomach trouble" to explain their 
diagnosis to the public. Relying on the symptoms 
they cannot have exact knowledge of the condition 
present. In many cases it may be said that a stomach 
specialist could do no better. Specialists have often 
been mistaken in their impressions gathered from the 
recital of the symptoms and assumed the existence of 
a hyperchlorhydria only to find on exact examination 
a total lack of acid in the stomach contents. The 
importance of laboratory diagnosis is thus clearly 



260 FERMENTATION IN THE STOMACH 

shown and it may be assumed almost as an axiom 
that a diagnosis of stomach disease based on the 
symptoms alone is little better than guess-work. 

THE RARITY OF FERMENTATION IN THE STOMACH 

Formerly it was a favorite custom to explain the 
belching of gas from the stomach and the flatulent 
distention of the organ as also the "sour" stomach, 
by saying that these symptoms arose from the fer- 
mentation of the food. Such an explanation gave rise 
to attempts to suppress fermentation by giving a host 
of antiseptics, some of powerful and some of feeble 
germicidal power. This explanation and the practice 
based on it arose from the application of a chemical 
theory without sufficient regard for the actual condi- 
tions prevailing in the stomach. The contents of the 
stomach are at times subject to fermentation with the 
production of a certain amount of gas. Lactic acid 
may be formed by fermentation but usually no gas 
is formed with it; butyric acid may occur in stomach 
contents and its formation is accompanied by the 
evolution of some gas ; yeast fermentation forms gas 
at times. However, if one will watch one of these 
fermenting liquids he will find that ordinarily the 
formation of gas is slow and quite insufficient to 
account for the belching that many patients experi- 
ence. These occasional sources of gas account for its 
accumulation only in rare cases. In the majority of 
cases the gas present in the stomach consists of 
swallowed air. As a rule even in cases in which much 
distress is produced by flatulence or belching there 
is no fermentation in the stomach. The swallowing 
of air may be a habit of voluntary origin or it may 
arise from the forcing or air through an atonic cardiac 
orifice by the force of expiration. The acid present 
in the stomach contents is seldom the result of fer- 
mentation but is produced by oversecretion of the 
gastric juice. It is well, therefore, to ascertain the 
true origin of these symptoms before attempting to 
prevent them by the administration of injurious anti- 
m ptics. 



ACUTE DYSENTERY 

Acute dysentery is an inflammation of the large 
intestine, throughout either the whole or a portion 
of its extent. Sometimes the lower part of the small 
intestine is coincidently inflamed. The disease may 
be due to various irritants of microbic or parasitic 
origin, giving essentially similar symptoms but requir- 
ing different treatment addressed to the cause of the 
disease. As Matthieu remarks we should not speak 
of dysentery but of "dysenteries" as there are several 
kinds of dysenteric colitis. It is, however, convenient 
to discuss the symptoms and general treatment in 
common for the different varieties and then take up 
the specific treatment of the different forms. 

The disease is characterized by mucus, blood and 
purulent discharges from the rectum, accompanied by 
much straining, colicky pains and tenesmus. The fol- 
lowing classes of dysentery may be noted : bacillary 
dysentery, amebic dysentery, balantidum dysentery, 
and dysentery arising from some unknown infection. 
The disease is, therefore, infectious and may be trans- 
mitted by the discharges or articles contaminated with 
them. It occurs in epidemics and also sporadically. 
When dysentery occurs sporadically it is generally 
more amenable to treatment. 

SYMPTOMS 

The general symptoms of acute dysentery are mild 
fever, a variable pulse, at times rapid or weak from 
exhaustion, with a tendency to collapse turns ; the 
movements are frequent and exhausting. The nearer 
the rectum the inflammation is, the more intense is the 
tenesmus and the more constant the desire to strain, 
with resulting small movements and but little relief. 
The higher up the inflammation is in the large intes- 
tine, the more frequent the griping and abdominal 
pain. The stools consist of large masses of mucus 
mixed with feces and later mucus, more or less blood- 
streaked, perhaps without any fecal matter at all. 
Later, slight hemorrhages occur, depending on the 
amount of ulceration or erosion of the membrane, and 
finally pieces of membrane are passed similar to diph- 
theritic membrane. The tongue is coated, but gener- 



r 



262 TREATMENT OF ACUTE DYSENTERY 

ally moist, unless a large amount of fluid is lost. If 
the progress of the disease is unfavorable, the tem- 
perature is likely to rise higher, otherwise it remains 
low. If the disease long continues and the movements 
are frequent and profuse, a typhoid state develops. 

GENERAL PRINCIPLES OF TREATMENT 

It is evident that the first steps in the treatment 
are rest, the removal of irritants, and the giving of 
most easily assimilable nourishment. These principles 
apply to all forms of dysentery. The patient should 
be put to bed and the use of the bed pan insisted on. 
It the condition of the patient will permit the rectum 
should be inspected with a speculum or with a procto- 
scope and a piece of mucus or a scraping from an 
ulcer if any are visible obtained for examination. 
This should be examined immediately on a warm 
slide for amebae which are recognized by the ameboid 
movements. If no amebae are found the mucus and 
feces should be examined bacteriologically for other 
causes of dysentery. Following this examination the 
rectum and colon should be irrigated with physiologic 
saline solution or a solution of methylene blue may 
be employed. After the fecal matter and mucus have 
been washed away and the water is returned clear, the 
colon may be treated with a weak permanganate of 
potassium solution, 1 : 10,000, or peroxid of hydro- 
gen solution 1 : 8 may be used. In making these 
irrigations the tube should not be pushed too far, 
which might increase the injury to the rectum. A 
few inches is sufficient. Such irrigations may be 
repeated once a day in the early stages. 

The Diet. — The diet should consist of milk and 
water, albumin water, rice water bouillon, beef juice 
or other suitable liquid food. If the tongue is coated, 
the other foods mentioned agree better than milk, but 
if the tongue is clean give milk either alone or diluted 
with some of the other foods. The food must be 
neither hot nor cold. Lemonade, tartaric acid lemon- 
ade, or imperial drink should be given. Milk predi- 
gested with pancreatin may obviate the tendency to 
the formation of an undue amount of intestinal gas. 



MEDICINAL TREATMENT OF DYSENTERY 263 

If milk is desirable but is distasteful, it may be 
diluted with Vichy ; or the milk may be given hot and 
salted. The milk given must be known to be pure and 
uncontaminated. If there is doubt, it must be pasteur- 
ized. Tea and coffee may be allowed at such times of 
the day as not to disturb the sleep. While large 
amounts of water are inadvisable and iced water 
should not be given, still, if much water is lost by the 
stools, the amount must be equaled by that which is 
ingested ; otherwise the patient's tissues lose water, 
the blood-vessels lose water, the urine becomes con- 
centrated, the skin dry, and the patient suffers from 
this deprivation of water, and such a condition alone 
may be the cause of death. Preferably, liquids or 
foods should be given hot, as anything cold entering 
the stomach is likely to start peristalsis. It may be 
advisable to give some thin cereal gruel once a day, 
at least if the disease lasts more than a week. 

As soon as convalescence is established, broiled 
lamb chops, roast beef, and the w T hite meat of chicken 
may be added to the diet. All solid food should be 
thoroughly masticated and the digestion may be 
hastened by giving a few drops of hydrochloric acid 
rdirectly after meals. As convalescence progresses 
favorably, toast, stale bread, and boiled rice may be 
added to the diet, and later baked potatoes. The first 
fruit that is allowable is either lemon or orange juice. 

MEDICINAL TREATMENT 

It is generally advised to give at once a dose of 
castor oil and follow it by small doses of calomel with 
additional laxative treatment in the form of saline 
laxatives if necessary. A good form of laxative is 
magnesium sulphate given in saturated solution in 
teaspoonful doses hourly. The following prescription 
is sometimes efficient in arresting milder forms of 
dysentery of unknown causation. 

Gm. or ex. 

I£ Magnesii sulphatis 25 Si 

Acidi sulphurici aromatici. 10 or A3 iiss 

Syrupi zingiberis 50 A3 ii 

Aquae ad 100 ad AS iv 

M. et Sig. : One teaspoonful in water every four hours. 



264 TREATMENT OF BACILLARY DYSENTERY 

This will have a laxative effect with a secondary 
astringent effect, due to the sulphuric acid. 

Bismuth subcarbonate may be administered in large 
doses, but the value of this is often problematical. 
However, if the inflammation is in the cecum or has 
migrated into the ileum, the bismuth is probably of 
value. Bismuth, however, must not be too long con- 
tinued, as it tends to form scybalous masses and cause 
more irritation and more inflammation. 

Pain should be relieved if necessary by opium. The 
tendency to tenesmus can be relieved by local applica- 
tions of cocain or one of its substitutes, or atropin 
(extract of belladonna). 

Kaolin or bolus alba has been recently revived as 
a remedy for dysentery. This treatment was in vogue 
more than a century ago but fell into disuse. It is 
claimed that the powder encloses the bacteria and 
prevents their pathogenic action. Probably this drug 
has an action in every way similar to that of bismuth 
in forming a protective coating to the mucous mem- 
brane. 

TREATMENT OF BACILLARY DYSENTERY 

The microscopic examination may show any one 
of a number of already classified dysentery organ- 
isms ; for example, the Flexner, Shiga, and other 
types. Such examination should include fermentation 
tests and other biologic reactions as well as a study 
of morphology. The classification, while a matter 
of great scientific interest, is not however, an im- 
portant guide for the prognosis or treatment. 

The general treatment already outlined is applicable 
to bacillary dysentery. Certain special measures also 
may be followed. 

Antidysenteric serum may be administered. A 
reduction in the mortality rate of bacillary dysentery 
from 30 to 50 per cent, through the use of some 
serums has been reported by some observers but not 
confirmed by all. It would seem the best results may 
be ascribed to an antitoxic action in infection with the 
Shiga-Kruse type of dysentery bacillus. The most 
favorable results are observed in the early stage of 
the disease. Mathieu (Abst. Jour. A. M. A., Nov. 
28, 1914, p. 1986) advises the administration of the 



TREATMENT OF AMEBIC DYSENTERY 265 

serum even before the diagnosis has been made in 
order to secure its early action. Shiga favors a poly- 
valent serum as meeting the requirements whatever 
the variety of organism present. 

If the disease progresses and immediate healing of 
the inflammation does not occur, and actual ulceration 
seems to have developed, as shown by the amount of 
bleeding, an occasional irrigation of nitrate of silver, 1 
part to 1,000 (not more than one pint at any one 
time, viz., 0.50 gram (7y 2 grains) to a pint of water) 
is of benefit. Such an injection should be given but 
once in four or five days, and if the liquid does not 
immediately flow out of the colon a solution of salt 
should be immediately injected. The salt forming an 
insoluble sodium chlorid, will prevent any poisonous 
absorption of nitrate of silver. 

TREATMENT OF AMEBIC DYSENTERY 

The diagnosis of amebic dysentery should always 
be confirmed by a competent study of the morphology 
of the organism isolated, as well as the injection of 
the organisms into the rectum of kittens. 

The general treatment of amebic dysentery is the 
same as that of bacillary dysentery. 

The specific treatment of amebic dysentery which 
is comparatively recent is with the aid of ipecac and 
emetin. 

Whether the amebae are on the surface of the mu- 
cous membrane, deeply embedded in the ulcers, or 
localized elsewhere in the body, they may be reached 
by properly administering ipecac and emetin. The 
amebae on the surface of the mucous membrane are 
not likely to be affected by emetin administered 
hypodermically. On the other hand, emetin given 
hypodermically becomes more quickly active on the 
deep seated organisms and the localized lesions. Jones 
(Jour. A. M. A. } March 20, 1915, p. 982) reports 
fifty cases occurring in the Philippines. The following 
method of administration is used at the Army hospital 
in Manila : 

Emetin hydrochlorid 0.008 gm. by hypodermic for 
ten days (twice a day for four days and once a day 
for six days). Ipecac started about the eighth day 



266 EMETIN IN AMEBIC DYSENTERY 

with from 1.5 to 2 gm. doses given at bedtime, con- 
tinued for three consecutive nights and thereafter 
decreased by 0.3 gm. each consecutive night. The 
disagreeable effects of the ipecacuanha were never 
manifested. It is quite necessary to precede the ad- 
ministration of ipecacuanha by tinctura opii in from 
0.6 to 1 gm. doses. 

Happy though the results of this combination may 
be in treating amebiasis, the fact should not be over- 
looked that emetin is an amebacide and has little to do 
with the healing of ulcerations. Every case of ame- 
biasis should, after this treatment, be considered one 
of ulcerative colitis and so treated from a dietetic point 
of view. At the same time every effort should be 
made to enhance resistance by change of climate, 
tonics, etc., to obviate the distressing sequelae charac- 
teristic of the disease. 

It should be remembered that even after the amebae 
have been removed, there still remain unhealed 
ulcers. These should be treated by rest in bed, proper 
diet and local irrigations. The latter serve not only to 
promote healing but also act to prevent relapses. 

Sulphate of quinin is believed by many to be specific 
in its destructive action on the ameba, and is much 
used for irrigating the rectum and colon. It should 
be used in a 1 to 5,000 to 1 to 1,000 solution. Cures 
are believed to have been effected by such irrigations 
in many cases. 

If, in spite of the remedies which have been enum- 
erated, the case still continues rebellious, resort to 
surgical interference may be deemed advisable, and 
appendicostomy may be performed, and irrigation of 
the colon by means of the insertion of an irrigation 
tube through the appendix may be practiced. This 
was referred to in Jour. A. M. A., Sept. 3, 1910, 
p. 858. 

Great care and patience are required in the treat- 
ment of this disease, and the treatment should be long 
continued, and after the patient is apparently cured, 
he should be kept under observation for months in 
order that, if a relapse occurs treatment may be 
promptly instituted. 

Abcess of the liver is a not infrequent complication. 
Such eases usually recover following emetin treat- 



GASTRIC AND DUODENAL ULCER 267 

ment if instituted early. It may be necessary, however, 
to open and drain especially in the event of secondary 
infection. 

Physicians should not temporize with inefficient 
medical treatment in severe cases of dysentery. There 
is a possibility of obtaining curative results by prompt 
surgical measures such as appendicostomy, etc., which 
may be life-saving. 

GASTRIC AND DUODENAL ULCER 

Ulcers occurring in the neighborhood of the pylorus, 
either on the lesser curvature in the pyloric antrum or 
in the first part of the duodenum, are probably due to 
similar etiology and have the same general character. 
They may, therefore, very properly be considered 
under the same head. Their causation is to be found 
in abnormal conditions affecting the nerves, the motor 
activity of the stomach and duodenum, the character of 
the food and the acidity of the gastric juice. An acute 
loss of the mucosa in a healthy stomach is rapidly 
repaired; an acute ulcer of the stomach commonly 
gets well rapidly. A chronic ulcer behaves differently, 
indicating that there is some complicating factor to 
keep it from healing. Considerable experimental work 
has been done to show that the nervous supply of the 
stomach is necessary to maintain a healthy condition 
of the mucous membrane. Further, the experimental 
work seems to show that a thrombosis of the blood 
vessels or an "infection" of an area of the mucosa is 
sufficient to cause the destruction of a portion of the 
mucosa and institute an ulcer. Ulceration thus pro- 
duced is favored and the necrotic tissue digested and 
carried away by a gastric juice of a high degree of 
acidity. A very marked influence prolonging the 
existence of such a lesion is the occurrence of pyloric 
spasm and the retention of the remnants of food and 
gastric contents containing a large proportion of hydro- 
chloric acid. In such cases the layer of protecting 
mucus is digested away and the ulcerated mucous 
membrane is exposed to long continued action of 
highly acid and irritating gastric contents. Turck 
has incriminated the colon bacillus ; Rosenow has 
shown that a particular form of streptococci may pro- 






268 SYMPTOMS OF GASTRIC ULCER 

duce gastric ulcer; when injected intravenously in ani- 
mals it almost invariably has this effect. 

The process of ulceration in the stomach in the 
light of our present knowledge may involve the fol- 
lowing steps : initial weakness or predisposition of the 
tissue probably due. to insufficient innervation ; initial 
injury in the form of abrasion, thrombosis, or necrosis 
from infection ; removal of necrotic tissue by active 
gastric juice; recovery in a normal stomach, but in 
the presence of pyloric spasm or of gastric stasis and 
the continued action of irritating food or secretions a 
continuance of chronic ulceration. In addition anemia 
must be put down as a complicating condition, although 
not always present. 

SYMPTOMS 

The symptoms of gastric ulcer are various, but a 
certain number have been considered classic and 
should be kept in mind by the physician as the basis of 
a diagnosis. At the same time the practitioner should 
bear in mind the fact that any of these signs may be 
absent or may fail to present their usual characters. 
The principal symptoms and signs are pain, vomiting, 
hematemesis, melena, tenderness at epigastrium, ten- 
der points near the spine. 

Pain in gastric ulcer occurs in attacks with intervals, 
sometimes of days or longer, and is excited by the 
digestive process, it does not occur immediately after 
taking food, but corresponds to the period of high 
acidity. It is aggravated by coarse foods, but often 
relieved by the taking of bland foods or of alkalies. 
The pain is referred to the epigastrium and does not 
necessarily indicate the exact location of the ulcer. 

Vomiting is likely to occur after the taking of food 
and has little that is characteristic about it when it 
does not contain blood. 

Hematemesis or the vomiting of blood is an import- 
ant symptom and when the other symptoms are pres- 
ent it may suffice to confirm the diagnosis of gastric 
ulcer. It must be remembered however that blood 
may be vomited after it is swallowed from pulmonary 
hemorrhage, or may be shed into the stomach from 
the bursting of a branch of one of the radicles of the 
portal vein or from an esophageal varix. The latter 






SYMPTOMS OF GASTRIC ULCER 269 

forms of hemorrhage are sometimes the result of high 
blood pressure in the portal circulation in hepatic 
cirrhosis, etc. 

The presence of large quantities of blood in the 
stools may be discovered macroscopically by their dark, 
tarry character. Such a condition of melena is cor- 
robative of the diagnosis of gastric ulcer, but other 
symptoms should be present to indicate that the 
stomach is the source of the bleeding before we should 
give the mere presence of blood in the stools much 
weight in the diagnosis of gastric ulcer. 

A tender point in the epigastrium is found in most 
cases of gastric ulcer. It corresponds to the location 
of the solar plexus and is elicited by slight pressure 
with the finger differing in this respect from the 
tenderness due to neurasthenia, which requires con- 
siderable pressure to bring it out. The tenderness of 
ulcer is referred to a point about midway between the 
ensiform cartilage and the umbilicus, the point being 
constant in one locality and strictly circumscribed. 

Nearly as constant and quite as characteristic are 
tender points felt sometimes on both sides, sometimes 
only on the left, in the dorsal region near the spinous 
processes of the tenth to twelfth vertebra. The dis- 
appearance of these tender points during treatment for 
ulcer is a valuable indication that the patient is 
improving. 

The diagnosis of gastric or duodenal ulcer may be 
confirmed by the Roentgen ray when observed by 
repeated pictures or by fluoroscopic observation. Test 
meals afford only corroborative evidence of the 
existence of an ulcer. Excess of free hydrochloric 
acid is usually present. There is frequently evidence 
of delay in evacuation of the stomach contents, and 
blood, either macroscopic or occult, is present in the 
majority of cases. The presence of occult blood in 
the stomach contents is not pathognomonic. Macro- 
scopic bleeding may be due to injury of the mucosa by 
the stomach tube. 

Occult blood in the feces is of more importance. If 
not constantly found, it is a strong indication of ulcer 
presumably in the neighborhood of the pylorus. 



270 TREATMENT OF DUODENAL ULCER 
ULCER OF THE DUODENUM 

The principal symptom is pain, more or less local- 
ized in the region of the pylorus, intermittent, occur- 
ring generally about two hours after a meal. In other 
words, this pain occurs when the stomach is more or 
less empty. This pain is more frequently relieved by 
eating some bland food or drinking milk than is the 
pain of ulcer of the stomach. The appetite is generally 
good, and vomiting and other symptoms of gastric 
indigestion are infrequent. Attacks of diarrhea may 
occur, and occult blood is often present in the stools. 
There may be marked hyperchlorhydria. 

TREATMENT 

One of the chief factors in the continuance of ulcer 
seems to be the irritating gastric contents which owe 
their irritating properties largely to their acidity. 
Hence the acid secretion should be reduced as a 
first step by regimen, diet and remedies. 

Not only should the degree of acidity be determined 
and search be made for any other condition of the 
stomach which might cause chronic irritation but the 
condition of other organs should be interrogated for 
other possible cause of hyperacidity and proper treat- 
ment should be applied. Medicinally the best reme- 
dies are alkalies combined with bismuth ; thus one 
may give 

gm. or c.c. 

B Magnesii oxidi 

Bismuthi subcarbonatis aa 15| or 3 ss 

M. Sig. : Take a small teaspoonful once in three hours. 

If such a powder tends to make the bowels too loose, 
sodium bicarbonate may be substituted for the mag- 
nesium oxid. Atropin or atropin sulphate may be 
given in doses of from 0.00025 gm. (gr. %5o), but the 
use of atropin should not be continued too long. 

As hyperacidity seems to increase the .ulceration, 
certainly increases the pain, and is likely to increase 
the vomiting, anything that diminishes the acidity is 
good treatment, and a diet free from the substances 
thai cause the greatest outpouring of hydrochloric acid 
is the diet of choice. In other words, a diet without 
meat and without meat broths, without toast, and with- 



DIET IN DUODENAL ULCER 271 

out any hard particles of food that can scrape or irri- 
tate the inflamed part, should be selected. The Len- 
hartz diet with raw eggs is the most sensible as giving 
nutrition and at the same time inhibiting the produc- 
tion of hydrochloric acid and tending to heal the ulcer. 

The raw eggs are beaten up whole and placed in a 
cup or glass surrounded by ice. The small amount of 
milk given is also served iced in the same manner, and 
the egg and milk feedings alternate with each other 
every two hours, at first two teaspoonfuls of the egg 
and four teaspoonfuls of the milk. The first day two 
eggs are used and six ounces of milk. The eggs and 
milk are gradually increased from this minimum until 
by the sixth day seven eggs and twenty-two ounces 
of milk are given. From the third day on a little 
granulated sugar is added. At the end of a week the 
number of eggs is reduced and some scraped beef is 
allowed, with soon a small amount of boiled rice. 
During the following week, the second week, the eggs 
may be soft boiled, and four may be administered a 
day, with the milk increased to nearly a quart, sugar 
as before, and scraped beef or chopped chicken and 
rice or bread with a little butter may be gradually 
added and the diet thus varied. Even when the eggs 
are used soft boiled, four should be taken a day. 
Whatever is taken, if solid, it should be very com- 
pletely and slowly masticated, and as above stated, at 
first the amounts ingested at one time must be very 
small and taken at intervals of two hours during the 
day. The foods for the first week should be taken 
cold and the next week only warm, never hot. Small 
sips of iced water may be taken as often as desired 
or advisable. 

In view of the hyperacidity, it is well to add to the 
diet as much fat as can w^ell be borne, in the form of 
butter or cream. 

During the first week the patient should be fed, 
not even allowed to feed himself, and he should remain 
in bed for at least three and better four weeks. 

If there is hemorrhage, an ice-bag should be placed 
over the stomach and a large dose of bismuth subni- 
trate should be administered, perhaps 3 or 4 grams (45 
or 60 grains) at once. 



272 HEMORRHAGE IN DUODENAL ULCER 

It generally seems advisable to give bismuth in large 
doses, at least 2 grams (30 grains) once a day. This 
can be taken stirred up in water or in milk and quickly 
drunk. 

The treatment above suggested generally stops the 
pain. If pain is still severe morphin should be resorted 
to, but with this treatment it rarely will be necessary, 
and the dose required, hypodermatically, is small. 

It must be remembered that the pain results from 
the presence of free hydrochloric acid and the fact 
that pain disappears gives no evidence that the ulcer 
is healed, but the lesion may still continue in a latent 
state and make its presence felt by symptoms when 
the increased acidity of a new attack sets up renewed 
irritation. Sippy's practice is to give alkali enough 
not only to relieve the pain, but also to neutralize all 
the free acid and keep it neutral during the greater 
part of the twenty-four hours. This is accomplished 
by repeated examinations of the stomach contents. 
The alkali is repeated whenever the examination shows 
that free acid is present. 

The patient should not get up to urinate or for the. 
bowels; a bed-pan should be used. If the patient is 
constipated the bowels may be moved by the rectal 
injection of a half ounce to an ounce of glycerin with 
an equal amount of w r ater and soap suds could be 
used if needed. 

As these patients are already short on iron and for 
a number of days are to receive no meat, it is advis- 
able to give the saccharated oxid of iron (eisen- 
zucker) 3 grains in tablet form twice a day. The 
patient should thoroughly crush the tablets with the 
teeth before swallowing. 

If after a month of this treatment the patient cannot 
normally convalesce and be apparently cured, in other 
words, if the symptoms quickly return, an operation 
should probably be recommended as the future of such 
a recurrent case is uncertain. Recurrent severe hem- 
orrhage should cause operation and of course when 
there is perforation operation is immediately neces- 
sary. 

Treatment of Hemorrhage. — In case of hemorrhage 
from the stomach perfect quiet, both mental and 



OPERATIVE INDICATIONS IN ULCER 273 

physical, must be insisted on. A hypodermic injection 
of morphin and atropin in full dose should be admin- 
istered. If the symptoms show that hemorrhage is 
persistent 1 c.c. (15 minims) of a 1:1,000 adrenalin 
chlorid solution in 30 c.c. (1 ounce) of distilled water 
should be given and followed in half an hour by from 
50 to 100 c.c. (about 2 to 3 ounces) of a 10 per cent, 
solution of sterile gelatin. Ordinarily food should 
be withheld from 48 to 72 hours, no food being given 
even by the rectum. As nutrient enemata have been 
shown to increase the flow of gastric juice, the first 
enemata should be normal salt solution and later pep- 
tonized milk and egg may be used. 

During the treatment of gastric ulcer the feces 
should be frequently examined for occult blood. When 
blood ceases to be present in the feces we have an 
indication that the healing of the ulcer is progressing 
and it is justifiable to use larger quantities of food and 
that of a more solid character. In case bleeding reap- 
pears after it has been absent for some days this 
should be taken as indicating the propriety of lessening 
the amount and simplifying the character of the food. 

Some physicians believe that morphin should never 
be given to relieve the pain of hemorrhage because it 
tends to increase the stasis and hyperchlorhydria that 
is present in ulcer. Gelatin may be given subcutane- 
ously and in certain cases Lindberg has found it advan- 
tageous to rinse out the stomach with a 1 per cent, 
solution of ferric chlorid. In removing this solution 
the aspirator should not be used but the liquid should 
be siphoned out of the stomach if practicable. 

OPERATIVE INDICATIONS 

When there is marked tenderness at a location 
aside from the region of tenderness common to the 
ordinary ulcer or if there should be a slight rise of 
temperature and an increased leukocytosis one may 
entertain the suspicion of an approaching perforation. 
In such case no delay should be permitted before open- 
ing the abdomen and ascertaining the true condition. 

The following may be given as indications for opera- 
tive interference in the case of ulcer of the stomach : 
1. Recurrent hemorrhage; 2. threatening perforation; 



274 .INTESTINAL STASIS 

3. failure of the case to improve under medical treat- 
ment applied with regularity for a reasonable time, 
say four weeks. 

INTESTINAL STASIS 

The term intestinal stasis has of late years been 
used to include what was formerly classed as consti- 
pation but with an extension to more serious cases 
which require surgical treatment. Intestinal stasis 
includes all cases in which the contents of the bowel 
fail to move in a normal manner whether the cause be 
a mechanical obstruction or a functional failure due 
to the character of the intestinal contents, or the 
functional activity of intestinal musculature. The 
stasis may occur at various locations in the gastro- 
intestinal canal but the usual location in the cases 
under consideration are ileal stasis in the lower part 
of the ileum, colonic stasis in various sections of the 
large intestine and stasis in the rectum. One of the 
most frequent kinds of constipation is that occasioned 
by an obstruction at the anal orifice due usually to an 
overaction or spasm of the sphincter muscle. Such 
cases are readily treated by relief of any cause of 
spasm and the gradual dilatation of the sphincter by 
bougies. In some cases an operation for the division 
of the semilunar valves or the valves of Morgagni is 
necessary. Hindrance to the evacuation of the feces 
may be due to a paresis of the rectum or sigmoid 
brought on either by repeated distention with feces 
or by the use of daily large rectal enemas. In these 
cases help may be obtained by daily diminution of the 
bulk of water used. A very frequent cause of consti- 
pation is insufficiency of feces resulting from the gen- 
eral insufficiency of the food taken or from the fact 
that it contains too little of the indigestible vegetable 
matter which favors the evacuation of the bowels. 
In such cases the feces are hard, and dry from the 
fact that during their stay in the large intestine the 
water has been absorbed to an undue extent. This 
form of constipation must be treated by proper diet. 

DIET 

The constipated individual should aim to add to his 
diet a larger quantity than normal of fluids either iti 



MASSAGE IX IXTESTIXAL STASIS 275 

the form of water or perhaps of buttermilk. Tea and 
coffee should be avoided because they contain tannin 
which may, by its astringent action, counteract the 
good effect of the larger quantity of liquid. Liquids 
should be given not only at meal times but in the inter- 
vals, in which case they serve better to replace the 
water absorbed from the large intestine. The diet 
for constipation should also contain as large an 
amount of fat as the patient can tolerate. The 
amount of vegetables which contain considerable 
quantities of cellulose should also be increased. This 
means plenty of vegetables. Fruits should be given 
freely, except the astringent fruits. The amount of 
water taken depends on the patient's habits and the 
condition of the circulation. A patient who is muscu- 
larly active should drink more water than the one 
whose life is sedentary. A glass of cold water drunk 
in the morning while dressing is a T great help to a 
physiologic movement of the bowels directly after 
breakfast. The morning coffee is also a stimulant to 
peristalsis. 

HABIT 

The patient should go to stool every morning at the 
same hour whether the desire is present or not, and 
should attend to the matter at hand, and, especially 
should not read for diversion. 

Abdominal massage, calisthenics, regulated exercise, 
walking, rowing, riding, golf playing, or any other 
muscular exercise that seems advisable should be 
ordered for the patient of sedentary habits, and it 
must be urged on him that if the habit of constipation 
is not now T cured the future promises intestinal indi- 
gestion, dyspepsia, imperfect action of the liver, imper- 
fect bile, nervous irritations, kidney irritations, and 
early cardio-vascular-renal disease, i. e., arteriosclero- 
sis, weakening of the heart, and chronic interstitial 
nephritis. 

MASSAGE 

Before any severe exercise or any abdominal mas- 
sage is ordered, or advised, a careful abdominal exam- 
ination should be made and the physician assured that 
there is no inflammatory conditions present, as chronic 



276 MEDICINAL TREATMENT IN STASIS 

appendicitis, gall-bladder disturbances, pelvic or other 
disturbances. 

Manual massage may be applied to the abdomen 
from fifteen to twenty minutes, beginning with light, 
circular stroking of the abdomen about the umbilicus, 
first having lubricated well the parts with olive oil. 
The course of the colon is gradually massaged deeply, 
all fecal masses broken up and moved down toward 
the rectum. When massage is deemed inadvisable or 
inconvenient, faradic electricity may be used. A large 
electrode may be over the lumbar or sacral spine and 
the other is moved over the abdomen, stroking from 
right to left. The current should be interrupted from 
two to six times a second, and the duration of the 
treatment and strength of current should vary with 
the results on the patient. 

MEDICINAL TREATMENT 

The best medicinal treatment of constipation con- 
sists in the administration of the fluidextract of rham- 
nus purshiana (cascara sagrada) or some form of 
aloes or aloin (generally best combined with bella- 
donna and strychnin). Sometimes podophyllin may 
be used separately or combined with other laxatives. 
There are no other laxatives or cathartics so likely 
to cure constipation as these drugs. Whichever one 
of these is u.sed, it should be given, week by week, in 
gradually diminishing doses. Whether they should be 
given in small doses three times a day, or larger doses 
once a day depends on the conditions. Generally, the 
patient not being sick and not willing to be bothered, 
and with the intent of having a stool after breakfast, 
and the medicine requiring a certain length of time to 
act, directly after supper or at bedtime, in one dose, 
is the best treatment. However, even with the best 
possible care, when these drugs are given, some 
patients require a dose daily for months and even 
years, and can not obtain a stool without it. This is 
generally not due to the action of the pill on the mind, 
as the substitution of an inactive tablet will prove. 

Perhaps the nexl best laxative is phenolphthalein. 
This drug seems to be harmless, and seems to act 
well, and if given in tablet, should be crushed with the 



SPASTIC CONSTIPATION 277 

teeth before swallowing, as it apparently acts better 
when well granulated. 

In the simple constipation that is now being dis- 
cussed it is inadvisable to resort regularly to enemas of 
any kind or to more brisk cathartics than those above 
mentioned or to saline cathartics. 

Cascara sagrada, as obtained from the drug stores 
is many times worthless, so far as laxative activity is 
concerned. On the other hand, some cascara prepara- 
tions offered to the profession contain other ingredi- 
ents than cascara, and consequently being more active 
are supposed by the physician to be more satisfactory, 
but the patient is really getting a more active drug 
than the physician desired. The physician should, 
therefore, be very careful to select and to obtain the 
best possible pure cascara sagrada preparation for 
each patient, and after finding the amount of this 
preparation that the patient needs for laxative effect, 
should gradually reduce the dose week by week until 
the patient is cured. 

SPASTIC CONSTIPATION 

This form, which is usually reckoned as a distinct 
variety, is characterized by the distress experienced 
during the act of defecation and by the appearance of 
the stools which are narrow, sometimes of the caliber 
of a lead pencil, and often covered with mucus. 
Sometimes separate masses of mucus in the form of 
strings or membranes are passed with the stool or at 
times when no stool is passed. This spastic form 
usually occurs in neurotic patients and the whole clini- 
cal picture is dominated by the nervous element. 
These cases should receive treatment appropriate to 
their nervous condition and they are also benefited 
locally by oil enemata given as a rule on alternate 
evenings. The technic of administering the oil is very 
simple. About 250 cubic centimeters of cottonseed 
oil, as warm as can well be borne, are injected through 
a funnel attached to a colon tube and allowed to remain 
in the rectum until the next morning. Patients unac- 
customed to these injections should put on a large 
diaper after the enema to obviate the danger of the oil 
leaking through the anus. It is necessary to recog- 



278 CAUSES OF CONSTIPATION 

nize a constipation of psychic origin and one due to 
habit which must be treated by suggestion and educa- 
tion with appropriate hygienic aids. 

What has been said above refers to the treatment of 
a symptom and only in the mildest cases is it curative 
in the sense of being addressed to the underlying 
lesion. Even in cases of spastic constipation which 
has been interpreted as a pure neurosis it is probable 
that an anatomic basis is present in the form of a 
colonic catarrh which is greatly aggravated by the 
nervous condition. Following Lane a large number of 
surgeons have explained the symptoms in a large cate- 
gory of abdominal and constitutional disorders as due 
to a mechanical hindrance to the passage of the intes- 
tinal contents and the consequent putrefaction occur- 
ring in the bowel. 

Ptoses of the various parts of the intestine are 
believed to form the basis of the obstruction from 
which the abnormal symptoms arise. In other cases 
it is supposed that adhesions, inflammatory mem- 
branes, etc., cause bends and kinks in the intestine 
which prevent the free movement of the intestinal 
contents. Unanimity in the interpretation of these 
facts has not been reached by clinicians. A number 
including Einhorn, Bastedo, Wilcox and others con- 
sider that the bands and ptoses do not account for the 
stasis inasmuch as the symptom of stasis is frequently 
intermittent and persons with equal mechanical hin- 
drances may be free from symptoms indicating the 
occurrence of putrefaction. 

Einhorn refers the doctrine of ptosis to Glenard. 
The theory of putrefaction and its resultant autoin- 
toxication is due to the teaching of Bouchard, Combe 
and others. This theory is made by Lane and his disci- 
ples the foundation for their plan of treatment. The 
digestive canal is called "a drainage tube" and com- 
pared to a sewer system in which any clogging must 
cause disaster. It has been asked if our body is 
resourceful in adequately fighting enemies that it lias 
never before encountered — pneumonia, typhoid fever. 
etc., how much more must we expect from it in the 
way of every-day defenses. It is surely well fitted to 
debar the entrance of harmful digestive products 



SYMPTOMATOLOGY OF CONSTIPATION 279 

through the intestinal wall, for this is a continuous 
happening. 

Unless there is a real mechanical obstruction or 
a definite organic lesion interfering with the intestinal 
current, a temporary delay of the contents may not 
be significant. It may even serve to make absorption 
more complete. 

With regard to the autointoxication theory, as far 
as it concerns intestinal stasis or habitual constipation 
the latter does not cause autointoxication. As is 
well known, a patient may have no bowel movement 
for several days and present no abnormal symptoms. 
The symptoms frequently associated with chronic con- 
stipation may be ascribed to nervous disturbances, and 
not to autointoxication. Reassurance and nerve seda- 
tives in such cases will often do more good than dras- 
tic measures. 

In mild cases Lane, following Glenard, recommends 
an appropriate abdominal supporting bandage. In 
the severer type Lane recommends operative mea- 
sures : ileocolostomy or colectomy. With this radical 
plan of treatment most clinicians and some eminent 
surgeons do not agree. 

SYMPTOMATOLOGY 

The symptoms of the milder forms of intestinal 
stasis are the same as those commonly attributed to 
constipation. Much of such symptomatology may 
result from the effect of ptosis on a neurotic constitu- 
tion and it is probably erroneous to attribute all symp- 
toms observed in such patients to intoxication from 
the intestines. A proper estimate of the effects of 
the various factors influencing the clinical course of 
such cases is important as indicating the relative 
importance to be assigned to different measures 
employed. Other symptoms are mechanical from the 
pressure of the delayed fecal masses, still others may 
result from dragging on the adhesions or bands con- 
necting different organs ; still others due to nervous 
reflexes from irritation or inflammation of the mucous 
membrane of the colon. Lastly there are symptoms 
of actual organic lesions which may result from putre- 
factive changes in the contents of the colon. Such 



280 DIAGNOSIS OF CONSTIPATION 

symptoms in severe cases may form a serious clinical 
picture. The following is given by Moynihan as 
characteristic of such a case : 

The patient is generally a woman of unhealthy aspect and attenuated 
figure. She is lean, cadaverous, flat-chested, and she has a sour 
breath and cold and clammy hands. The skin is harsh and of an 
earthy color and bears many crops of pimples; its secretion is apt to 
be distressingly noticeable. She makes complaint of "indigestion," pain 
after meals, flatulence, and inveterate and incoercible constipation. 
The abdominal muscles lack bulk and tone. They are flabby and 
flaccid, and all the viscera which they should hold up are fallen in 
greater or less degree. Mentally, there is often a complete absence 
of the joy of life; the patient is a morose, querulous, and often 
suspicious and introspective person. These attributes are rarely all 
present together, but so many of them may coexist as to enable a 
distinct type of patient to be recognized. In the very obvious cases 
of this kind, Moynihan does not think the mild measures that can 
often usefully be employed for the novice — massage, abdominal exer- 
cises, and the unrestricted use of paraffin — are really of any value. 
These sufferers are properly cases for surgical treatment. The colon 
should be excised in whole or in part. In some, perhaps, ileosig- 
moidostomy may be done; but in every case, with one exception, in 
his own series there has been some regurgitation of the intestinal 
contents upward along the descending colon to the cecum. The stasis 
then is worse than before, for a mass of fecal material that is never 
wholly dislodged is palpable at all times. 

DIAGNOSIS 

It is fortunate that we possess means of making an 
accurate diagnosis of intestinal stasis by means of 
Roentgen-ray examinations, either radiographs or flu- 
oroscopic examinations. In this way the length of 
time that is required for food to pass through the 
different sections of the intestine can be determined 
and it may be learned at what point the delay, if any, 
occurs. Abnormalities in the contour and position of 
the different parts of the intestine can also be deter- 
mined in the same way. The existence of intestinal 
putrefaction is shown with certainty by the appearance 
of indican in the urine. The extent of the putrefactive 
changes are not, however, easily estimated in this way. 
If, on shaking out the urine with chloroform after 
treating it with Obermeyer's reagent (a solution of 
ferric chlorid in strong hydrochloric acid, two parts to 
one thousand) the chloroform has a deep blue color, 
a considerable amount of indican is present, and it is 
justifiable to assume that there is a considerable degree 
of intestinal putrefaction. 



HYPERACIDITY 281 



TREATMENT 



The treatment of mild degrees of intestinal stasis 
is the treatment of constipation as previously out- 
lined. To this should be added such mechanical sup- 
ports as are necessary to obviate the effects of ptosis 
of the intestine. As a laxative agent Lane has strongly 
recommended paraffin oil. Bastedo and more recent 
literature generally object to the use of the ordinary 
drug laxatives and recommend the use of agar-agar 
or of paraffin oil. The oil to be employed is of the 
variety known as Russian oil and should correspond 
to the tests laid down by the Council on Pharmacy 
and Chemistry. 

Surgical Treatment. — The question of what surgi- 
cal measures shall be resorted to and the proper time 
to apply them is very important. Medical treatment 
should be given a thorough trial. If medical measures 
fail operation may be resorted to. Moynihan believes 
that nothing short of colectomy offers a substantial 
chance of cure. The part of the gut that needs 
removal is, he thinks, the last part of the ileum, the 
cecum, and the ascending colon. A. Primrose reaches 
the following conclusions : "Where ill health caused by 
intestinal stasis resists ordinary medical treatment then 
surgical intervention of suitable character should be 
undertaken. 

According to A. McPhedran (Canadian Med. Assoc. 
Jour., Nov. 1914) two classes of cases will require 
surgical aid: (1) those with organic obstruction which 
cannot be overcome by the above means, and (2) 
those who cannot secure the necessary care and super- 
vision, or cannot take the necessary time to effect the 
needed relief. In most cases, however, the time 
required probably will not in the end be greater than 
that necessary for relief by surgical means. 

HYPERACIDITY 

The changes of opinion that have occurred and the 
changes in method of treatment in the so-called hyper- 
acidity of the stomach have been reviewed by Adolf 
Schmidt of Halle, Germany (Jour. A. M. A., Feb. 7, 
1915). Practically the term is taken to mean cases of 
increasing gastric disturbance, appearing at various 



282 CAUSES OF HYPERACIDITY 

intervals after meals, or the ingestion of special kinds 
of food ; heartburn is a common accompaniment. 
Tests with the stomach-tube reveal either hyper- 
acidity or hypersecretion, and the latter may be sepa- 
rated into a digestive and continuous type, The latter, 
when appearing periodically, is known as Reich- 
mann's disease or gastrosuccorrhea. Pawlow's 
opinion, that pure gastric juice has the same percent- 
age of hydrochloric acid, must in the light of recent 
research be abandoned unless we assume that the 
superficial epithelium produces concentrated alkaline 
fluid, together with pure gastric juice, which is para- 
doxical according to Gregerson. Schmidt concludes 
that the stomach secretion must vary under pathologic 
conditions. Nervous influences come into play and the 
question arises whether or not there is an etiologic 
relationship between the hyperacidity of the stomach 
and the subjective symptoms. The anamnesis must 
not be depended on without the use of the stomach - 
tube. Still more important is the question whether 
this hyperacidity occurs as a disease dependent only 
on nervous causes, or whether it always has some 
organic lesion as a cause. The old notion that it was 
a pure gastric neurosis has changed on account of the 
rediscovery of duodenal ulcers. The purely nervous 
cases are less to the fore, but we would be premature 
in entirely denying hyperacidity in some cases as a 
unit per se. 

C. H. Neilson, St. Louis (Jour. A. M. A., Feb. 7, 
1915), considers hyperacidity a symptom of disease 
rather than a disease itself. It frequently occurs in 
the sedentary and overworked and in connection with 
other abdominal disorders, such as appendicitis, gall- 
stones, enteroptosis, uterine displacements, etc. It is 
also an early sign of the beginning of hyperthyroidism 
and of tuberculosis, and it may be clue to ear troubles 
or eye-strain. It is a complex affair to deal with, and 
hence calls for a correct diagnosis of the causal con- 
ditions, with the removal of which the hyperacidity 
often disappears. In addition to these general or 
exciting causes, the local conditions in the stomach 
must be considered. Any one who has had hyper- 



• 



TREATMENT OF HYPERACIDITY 283 

acidity for any length of time will have certain path- 
ologic changes in the gastric mucosa, hypersecretion 
and hyperesthesia, and we often find pylorospasm, 
hypermotility or gastroptosis. He divides hyperacidi- 
ties as follows: "1. Chemical hyperacidity with a 
normal quantity of gastric content after a Boas-Ewald 
test breakfast. 2. Chemical acidity combined with 
hypersecretion or with a continued secretion. Here 
the quantity of gastric content is abnormally and con- 
stantly large. 3. Chemical hyperacidity combined with 
hypersecretion and hyperesthesia. 4. Clinical or 
symptom hyperacidity with hyperesthesia. In this 
class of cases we have all the subjective symptoms 
of a chemical hyperacidity. In these cases we find 
a normal total acidity or even a subacidity. The symp- 
toms are due to the hyperesthetic condition of the 
gastric mucosa, which is painful in a normal or even 
subnormal acid content. 5. In this class we may 
find any one or a combination of the foregoing, 
together with pylorospasm, hypermotility or peristaltic 
unrest." 

TREATMENT OF HYPERACIDITY 

In treatment the principal point is, not to confine 
treatment entirely to the stomach, but also to calm and 
strengthen the nervous system. Some patients are 
best treated by being sent at once to a hospital or 
sanatorium, and Schmidt demands this in every severe 
case. Naturally, we try first to reduce the secretion. 
Atropin acts this way, but its continuous use is not- 
advisable, nor is that of the alkalines, which may irri- 
tate the stomach glands. Schmidt favors the use of 
the magnesium oxid, combined with a small amount of 
belladonna and a purgative, such as sodium sulphate. 
Silver nitrate owes its excellent effect on hyperacidity 
to its astringent effect on the circulatory cells and 
partly to its blunting the hyperirritability of the 
mucosa. For the latter purpose it should be given 
half an hour before meals ; for the former, a solution 
to rinse the stomach in the morning by the tube. Diet 
is perhaps more important, and foods that act as secre- 
tory stimulants, like spices, coffee, strong alcoholics, 
etc., should be avoided. As to special diets, it is dif- 



284 DRUGS IN HYPERACIDITY 

ficult to keep them up for any length of time, and 
Schmidt has long returned to a mixed diet and strict 
observance of the following rules : All food must be 
thoroughly cooked and carefully minced. The stom- 
ach must come to rest at least once during the twenty- 
four hours and the times of the meals changed to 
secure this. Drinking should be generally diminished 
and restricted to times when the stomach is not filled 
with food, especially in cases of ptosis. If the condi- 
tion is severe or combined with ptosis, he makes the 
patient stay in bed for two weeks, and this he con- 
siders important. Sometimes hot compresses are used 
to bring relief — twice daily for two hours. At night 
they are replaced by cold hydropathic compresses. 
Washing the stomach is indicated only when the 
hyperacidity is based on catarrh. Temporary relief, 
however, will always be afforded by the administration 
of an antacid, and the burning, distress, pyrosis, and 
flatulence that may be present will all be made imme- 
diately better by the administration of 1 gram (15 
grains) of bicarbonate of soda. Such treatment is, 
of course, purely symptomatic. . If it is advisable to 
give bicarbonate of soda, which is perhaps the best 
of all the antacids, three times a day, before meals, the 
dpse should be smaller, perhaps generally 0.50 gram 
{7 J / 2 grains). It will act, as above stated, as agastric 
sedative and will soothe the irritated mucous mem- 
brane, will cause a quicker outpouring of the hydro- 
chloric acid, and will thus hasten the completion of 
the stomach proteid digestion ; all of which will tend 
to make the disturbance and the dyspepsia better, but, 
unless there is actual inflammation of the stomach, 
is not treating the cause. If gastritis is present, no 
one treatment is perhaps more successful than the 
combination of bismuth and soda, as : 

gm. 

ty Bismuthi subnitratis 20 1 or 3 y 

Sodii bicarbonatis 10 1 3 iiss 

M. ct fac cbartulas, 20. 

Sig. : A powder tbrcc times a day, before meals. 

A glass of hot water taken a half-hour before the 
meal to wash off the mucus from, and to deplete, the 



TAPEWORM 285 

inflamed gastric mucosa is, of course, excellent treat- 
ment. 

If the antacid is given after a meal the digestion of 
the starchy foods will go on longer than usual on 
account of the alkali keeping the contents of the stom- 
ach longer alkaline, viz., free hydrochloric acid or a 
large amount of acid peptones will not so soon be 
present to inhibit further salivary digestion. 

If with the dyspepsia, or gastritis, constipation is 
present, some magnesium oxid should be added to the 
above prescription or substituted for the sodium bicar- 
bonate. Also in hyperacidity the precipitated car- 
bonate of lime is used, and is often a most successful 
treatment. 

If an antacid is indicated and diarrhea is present, 
it is advisable to use lime water. 

If an acute hyperacidity is present and there is pal- 
pitation or cardiac disturbance, hysterical or other, the 
aromatic spirits of ammonia is perhaps the best ant- 
acid to use. 

If for any reason alkalies must be administered for 
some time, it should be remembered that the sodium 
salts are better tolerated than the potassium salts, as 
potassium is depressant to muscles, while sodium 
is hardly a depressant at all. 

As regards operation, the necessity varies according 
to the case. Schmidt advises an operation in a young 
man in active business who wishes at all costs to get 
rid of his pains, rather than in one who is not so 
pressed and can stand his troubles and regulate his 
diet. The manner and extent of the operation must be 
determined by the findings, such as ulcer, gall-stones, 
adhesions, etc. If there are no anatomic lesions at all 
found, he would advise gastro-enterostomy without 
closing the pylorus and the dietetic and other treat- 
ment continued. In no case should the patient be per- 
mitted to get up and eat anything he wants too soon 
after an operation. 

TAPEWORM 

Treatment to eradicate a tapeworm is based on 
several factors which, though simple, are fundamental. 
The treatment should be grounded on a knowledge 
of the worm, its pathology and method of existence. 



286 TREATMENT OF TAPEWORM 

The diagnosis of the presence of any of the tape- 
worms in the bowel must be finally settled by the find- 
ing of the organism in the stools. However, other 
phenomena such as indefinite pains, a sense of disten- 
tion, ravenous hunger, etc., are not unusual. 

Before administering the anthelmintic several days 
should be devoted to the preparation of the bowel. 
The patient should take only a light liquid diet and 
should gradually cleanse the bowel by the use of the 
following prescription : 

gm. or ex. 

fy Magnesii sulphatis 60| 3 ii 

Spiritus chloroformi 12| or A3 iii 

Aquae ad 180| AS vi 

M. et Sig. : A tablespoonful, in water, three times a day, 
an hour before meals. 

An enema of soap and water may be given at night. 
This treatment removes solid fecal mater from the 
bowel as well as any adherent mucus coating which 
may be present. The night before the final treatment 
is to be administered the patient is given a final 
cleansing dose, perhaps two tablespoonfuls of the 
above mixture, and then takes no food and but little 
liquids. The next morning after the bowels have 
moved male fern may be given as follows : 

gm. 

I£ Oleoresinae aspidii 4| or 3i 

Fac capsulas, 8. 

Sig. : Four capsules, with half a glass of hot water at 9 
a. m., and four capsules, with hot water, at 10 a. m. [Impor- 
tant : Before taking the above capsules "each one should be 
uncapped.] 

At 12 o'clock three tablespoonfuls of the magnesium 
sulphate mixture should be taken to insure the rapid 
passage of the male fern through the intestine lest 
too much absorption take place. 

During the morning no nutrition should be taken 
other than black coffee, clear tea, or bouillon. 

Except when momentarily otherwise engaged, the 
patient should be in bed, and should stay in bed the 
remainder of the day. For unavoidable faintness 
brandy may be administered at any time, or a hypo- 
dermatic" injection of strychnin may be given. After 1 



ROUND WORM 287 

o'clock any food may be given the patient that he 
desires. 

During the three or four hours of this active treat- 
ment, viz., from 10 a. m. to 1 or 2 p. m., the physician 
should remain with the patient, or a thoroughly trained 
nurse should be in attendance. 

The stools should all be passed into receptacles 
where they can be thoroughly strained afterward in 
order that the parasite's head may be sought, and if 
the above treatment is carried out it will generally 
be found. 

Pomegranate has been highly lauded by various 
physicians as an efficient anthelmintic in these cases. 
It is best given, after thoroughly cleansing the patient's 
bowel as has been described, in the form of a fresh 
infusion. Three ounces of the fresh bark are macer- 
ated in twelve ounces of water for a half day and 
the infusion then boiled down one-half. This quan- 
tity is taken within an hour in several doses and fol- 
lowed within an hour or two by castor oil. 

Pomegranate may cause dizziness and extreme 
nausea where given in this form. As alternative an 
alkaloid derived from the bark — pelleterin tannate — 
is sometimes used. The dose is from 3 to 6 grains, 
and should be given fasting, mixed with a little water. 
A glass of water should be taken a little after its 
administration and an hour afterward a cathartic. 

Other vermifuges include turpentine, kousso, pump- 
kin seed and thymol. 

ASCARIS LUMBRICOIDES : ROUND WORM 
The round worm is a common parasite, often very 
difficult to diagnose. The symptoms are indefinite and 
include vague colicky pains, foul breath, itching at 
the nose, etc. The common source of infection is 
water or food. The finding of the worm in the feces 
is the final proof of its existence. It is of reddish 
brown color, about %-inch in diameter. The male 
varies in length from 4 to 8 inches, the female from 
6 to 12 inches. Though the intestinal tract is the nor- 
mal habitat the worms wander, and they have been 
found in the larynx, nose, Eustachian tube, tonsil and 
other contiguous structures. 



288 PIN WORM 

TREATMENT 

The diagnosis having been confirmed treatment 
should be begun by administering laxatives at night to 
cleanse the bowel. Santonin is a favorite vermifuge 
in these cases, but many cases of poisoning have 
followed its use and it should be given with caution. 
The dose is 2 to 5 grains. The drug may be admin- 
istered in the following form : 

gm. or c.c. 

I£ Santonini 30 gr. v 

Hydrargyri chloridi mitis 20 or gr. iii 

Sacchari lactis 3 gr. xlv 

M. et fac chartulas 10. 

Sig. : A powder, in water, every hour for three doses. 

Considerable discussion has occurred as to whether 
Santonin may not be administered in castor oil to 
advantage and there is much good clinical authority 
for its use in doses of two or three drops in a dram 
of castor oil. 

Thymol has been used with good results in these 
cases and wormseed oil (oleum chenopodii) , an Amer- 
ican product, has given good results. The dosage of 
the latter may be five drops on a lump of sugar and 
this may be repeated and followed by a cathartic. 

OXYURIS VERMICULARIS : PIN WORMS 

This worm varies in length from 1/5-inch for the 
male to 2/5-inch for the female. The former has 
a blunt tail, curved upward, the female a pointed 
drawn out tail. The most common symptom is itching 
about the anus, caused by boring movements of the 
female in depositing eggs in the rectum. The worm's 
chief habitat is the bowel from the jejunum to the 
anus. It is believed that the source of infection is 
the swallowing of ripe eggs in drinking water or food. 

The treatment consists in removing the worms by 
frequent washing of the region infected. Internally 
salts, such as magnesium or sodium sulphate, may 
be given, or large doses of calomel. 

To dislodge the worms from the rectum enemata 
should be given. Among various enemata which have 
been recommended are decoctions of quassia — an 



TREATMENT OF PIN WORMS 289 

ounce of quassia chips in a pint and a half of water 
boiled down to a pint and strained; lime water; salt 
water; glycerin and water; turpentine — 1 dram to a 
pint of soap and water, etc. 

For local itching and abrasion such ointments as 
the official unguentum phenolis (3 per cent.) or some 
mild sulphur ointment may be employed. 



DISEASES OF THE KIDNEY 



PYELITIS 

The causes of infection in the kidney, as elsewhere 
in the body, may be stated as a lowered resistance 
of the tissue and an organism capable of infecting 
the kidney tissue, coming usually from a focus else- 
where in the body. Barber and Draper have shown 
that ascending infection by the ureters seldom if ever 
occurs as long as the peristalsis of the ureters is 
unimpaired and the uterovesical valves maintain 
their integrity. Most infections are therefore 
hematogenous. Among the factors lowering the 
resistance of the kidney tissue, nephrolithiasis or 
kidney stone, is perhaps the most common cause, 
others being traumatism, urinary obstruction, dis- 
placement, etc. The pyelitis of pregnancy arises 
from pressure of the gravid uterus which may 
mechanically obstruct the ureters. Not infrequently 
the pyelitis is a complication of such acute infectious 
fevers as typhoid and pneumonia. Among the vari- 
ous focal infections which may bear an etiologic 
relationship to pyelitis are tonsillitis, alveolar 
abscesses, and infections of the accessory nasal 
sinuses. 

According to MacGowan {Jour. A. M. A., Jan. 16, 
1915) the organisms producing pyelitis are, in the 
order of their frequency, colon and tubercle bacilli, 
staphylococci, streptococci, gonococci, typhoid bacilli, 
paratyphoid bacilli and pneumococci. These infections 
are simple metastases. They occur rapidly, arc 
usually acute and persistent, may cause multiple 
abscesses and also may destroy the kidney and often 
the life of the patient. In their early diagnosis the 
chief means is exclusion, as the symptoms are essen- 
tially abdominal and may simulate other troubles 
like appendicitis, liver disorder, etc. The most 
prominent symptom in kidney suppuration besides 



TREATMENT OF PYELITIS 291 

fever is marked tenderness at the costovertebral angle, 
which is always present. The urine does not indicate 
the micro-organism and in advanced or serious cases 
it will contain leukocytes and there w T ill be a leuko- 
cytosis, usually not over 25,000. A severe chill usually 
means a high grade of infection. Staphylococcus and 
streptococcus nephritic attacks are most frequent and 
have been observed following boils, tonsillitis, acute 
osteomyelitis, felon, ulcerations about the rectum and 
contagious impetigo. 

TREATMENT 

In arranging the treatment for pyelitis the cause 
must be sought, that is, the focus, the nephrolithiasis, 
or cystitis. According to MacGowan these infections 
divide themselves into two classes as regards treat- 
ment: First, those that are cured with an abundant 
use of water, vaccines, diet, rest, hexamethylenamin. 
potassium nitrate and mild diuretics ; second, those 
that require incision and decapsulation, opening of 
abscesses and drainage. In the first type the patient 
should be kept absolutely at rest in bed on a soft meat- 
free diet. The liquid intake should be sufficient to 
cause the patient to pass from two to three liters of 
urine daily and thus flush the kidneys out thoroughly. 
The medicinal treatment of pyelitis depends on 
whether the urine is acid or alkaline. If the patient 
is troubled by frequency of and distress on urination 
it is best to render the urine alkaline as it is then less 
irritating. The alkalinization of the urine is further- 
more an excellent method of treating the pyelitis for 
the bacteria causing the pyelitis do not thrive in an 
alkaline medium. The alkalinization of the urine 
may be accomplished by the use of alkaline drinking 
waters, of fruit juices of acetates, citrates or carbon- 
ates. The carbonates are the most effective, but are 
not always well tolerated by the stomach, in which 
case some of the other salts may be tried. It is best 
to use this method of treatment until the bladder 
irritability has disappeared and then to allow the 
urine to become acid and to prescribe hexamethyl- 
enamin for a few days until the bladder becomes 



292 TREATMENT OF PYELITIS 

irritable again, when the alkaline treatment is resumed. 
Other drugs such as salol, methylene blue and the oils 
of turpentine, sandalwood, juniper and copaiba have 
also been used in the treatment of this condition. 

Colon bacillus infection is the most frequent type, 
is persistent and requires the removal of the original 
focus. The attacks occur at uncertain intervals and 
frequently cause great pain. The urine is practically 
always acid and distinguished from that containing 
other infecting organisms, except the Proteus Hauser 
by its remaining turbid on standing. From the proteus 
it is distinguished by the putrid fecal odor and its 
acid reaction and the triple phosphate crystals 
observed with the latter. The first symptoms are 
often those of a light cystitis. Constipation is an 
etiologic factor and any slight injury to the mucous 
membrane of the bowel gives an entry to the infection 
in the blood whence it may reach the kidney through 
any injury there. Some cases are amenable to purely 
medical treatment, diet, etc., and MacGowan speaks 
highly of the relief afforded by ureteral catheterization 
and pelvic lavage with weak solutions of silver nitrate, 
aluminum acetate and mercuric oxycyanid from 
1:10,000 to 1:5,000. Argyrol, collargol and other 
silver preparations have also been mentioned for this 
purpose. It should be remembered, however, that 
ureteral catheterization requires expert service. In 
children in whom the disorder is common the majority 
of cases will yield to alkaline treatment and sweat 
baths. Vaccines are useful in colon bacillus infections, 
especially autogenous vaccines, but they must be used 
with great caution, as violent reactions may be pro- 
duced. Pyelitis gravidarum is considered with colon 
bacillus infection as this is the cause in 70 per cent. 
It is a serious infection, and whenever, in a gravid 
woman, some unknown fever appears and there is 
very slight pain at the costovertebrae angle at one 
side, it is well to search in the urine for the colon 
bacillus. With attention to the prodromes, ureteral 
catheterization and lavage will often abort an attack. 
Rest in bed and diuresis are essential. If the child has 
a right lateral position, have the woman lie on the left 



RENAL TUBERCULOSIS 293 

side and vice versa. The prognosis is usually good for 
the mother as to saving her life but not for a per- 
manent cure, and it is always bad for the child. 
MacGowan always advises the induction of prema- 
ture labor unless contraindicated. 

Renal tuberculosis is a progressive infection, slow 
in its development, often remittent and probably incur- 
able by medical means. It may appear in the miliary 
form as a part of a general tuberculosis. There also 
fxists a chronic parenchymatous nephritis occurring 
in the later stages of lung tuberculosis. According 
to some writers there is an interstitial tuberculous 
nephritis. Fourth, and most important, is the type of 
minute focal infections tending to coalesce almost 
invariably unilateral at first and occurring in persons 
not affected with active tuberculosis. This is the 
form usually meant by the term renal tuberculosis. 
There are no diagnostic symptoms for the early stages. 
The first is vesical irritability, followed later by 
albuminuria and perhaps hematuria. It is apt to be 
confused by the practitioner with renal stone, though 
that is a much rarer condition. Pus in the urine is not 
long delayed and with it Koch's bacillus appears. The 
blood stream is the mode of invasion except in very 
rare cases. One kidney is first affected in most cases 
but the other kidney later becomes involved. When 
operation is refused the other kidney usually becomes 
affected in three years and the patient dies within five. 
After the bacillus is discovered the diagnosis is clear 
but the cystoscopic appearances will confirm it. There 
are two ways of treating the patient, either the general 
treatment for tuberculosis or nephrectomy, which 
gives immediate relief in 75 per cent, of cases, and 
permanent cures in 50 per cent. MacGowan does not 
put full confidence in tuberculin treatment in these 
cases ; if used the dose should be very small at first. 

In malignant or explosive types of pyelitis, with 
great depression and marked toxemia, nephrectomy is 
the only remedy, if the case is unilateral. Any 
obstruction to urine must be removed and if a stone 
is present, it must also be removed. 



ACUTE NEPHRITIS 

Acute nephritis arises as a result of injury to renal 
parenchyma due to bacterial infection or chemical 
toxins. To the first of these belong the acute nephritis 
of scarlet fever and the other acute infections, though 
there may be a toxic element in addition. The classical 
example of the infectious type of acute nephritis is 
that which follows an acute tonsillitis or sinusitis. As 
examples of the toxic type, we have the cases follow- 
ing extensive burns and poisoning with such sub- 
stances as turpentine, cantharides, phenol, the sali- 
cylates, potassium chlorate, iodoform, mineral acids, 
arsenic, phosphorus, mercury and lead. The acute 
nephritis of pregnancy is also in all probability of 
toxic origin. Alcoholism is of itself probably not a 
cause of nephritis, but the exposure that so often 
accompanies excessive use of alcoholics may give rise 
to an acute infection which is the cause of the 
nephritis. Dick has shown that bacteria are present 
and responsible in nearly all types. 

As to prognosis, the acute nephritis may clear up 
entirely, it may become chronic, or it may end fatally 
due to uremia, anasarca, or to a pneumonia or other 
terminal infection. A condition which sometimes fol- 
lows an acute nephritis should be mentioned ; in some 
cases there results a permanent albuminuria which is 
not, however, accompanied by symptoms of renal dis- 
ease. In fact, in these cases there is no impairment of 
renal function as shown by such functional tests as 
the phenolsulphonephthalein test. The cause of this 
albuminuria is probably a permanent cicatrization in a 
portion of one or both kidneys which is, however, not 
sufficient to impair the renal function. 

There are two rather diametrically opposed methods 
of treating acute nephritis, one based wholly on clinical 
experience and the other principally on the experi- 
mental work of Martin II. Fischer. 

Fischer in his experimental work has shown that 
acidosis will cause edema and albuminuria and that 
this edema and albuminuria can be overcome by over- 
coming the acidosis with alkalies. He argues that in 
nephritis we have conditions similar to those that he 



TREATMENT OF NEPHRITIS 295 

has experimentally produced by acidosis and over- 
come by the use of alkalies. Further, he has shown 
that by using sodium chlorid, a smaller amount of 
alkali is needed to overcome the acidosis and the 
resulting edema. He has outlined a treatment for 
nephritis based on this experimental work which in 
many cases seems to produce better results than any 
other treatment. He recommends that this hypertonic 
solution (sodium chlorid 14 grams, sodium carbonate 
10 grams and water 1,000 c.c.) be given per rectum; 
this is best given by the drop method and, unless the 
patient is becoming uremic, 500 c.c. at a time twice 
a day. If the patient is showing symptoms of impend- 
ing uremia 1,000 c.c. may be given per rectum or even 
intravenously. In giving the solution intravenously 
care must be taken that none of the solution enters 
the tissues as the hypertonic solution may cause a 
slough. The best method of giving it intravenously is 
through a needle into one of the veins of the forearm, 
such as the median basilic vein ; the solution should 
enter slowly so that it may be well mixed with blood. 
Fischer's directions should be followed in preparing 
the solution for intravenous use. In addition to the 
above intravenous or rectal medication, he recom- 
mends giving alkalies and sodium chlorid by mouth. 
The alkalies may be given in water or in fruit juices. 
The liquid intake is not limited, but all liquids should 
be isotonic or hypertonic so as not to overcome the 
effect of the solution given per rectum. The diet is 
composed of soft foods which are heavily salted. The 
patient should be kept at rest in bed until well on the 
load to recovery and then allowed up a little more 
each day. The bowels should be kept moving freely 
by the use of mercurials and salines, and if the enemas 
are not retained opium suppositories may be used to 
make the rectum more tolerant. The total liquid 
intake and output must be accurately measured to 
make sure the edema is lessened. 

The other method of treatment, which is based on 
clinical experience, is diametrically opposed to the 
above. In this the amount of liquid intake is limited 
to 1 to 1.5 liters, and the amount of sodium chlorid 
reduced to a minimum, even salt free bread being 



296 TREATMENT OF NEPHRITIS 

used. Otherwise the diet is about the same, though 
in severe cases it is limited to milk. The bowels are 
kept moving freely and elimination is promoted by 
the use of hot air sweats and rarely by the use of 
diuretics. When uremia seems to be impending, cases 
being treated in this manner are given sweats and at 
times subjected to venesection, as much as 500 c.c. 
of blood being withdrawn in certain cases. Rest in bed 
is of course necessary under this treatment. Accur- 
ate measurements of the total liquid intake and output 
should be made in all cases of nephritis, as this gives 
the best indication of the results that are being 
obtained. 

While the Fischer treatment does not seem to work 
in every case, it produces such rapid results when 
it is beneficial that it should perhaps be tried first. 
Of course the sweats may be used in conjunction with 
this method of treatment as may venesection. If the 
alkali treatment does not work, the other older method 
may be attempted. General supportive treatment may 
be added as indications arise whichever method is used. 

Of course whenever possible and as soon as possible 
the cause of the nephritis must be removed. In cases 
following tonsillitis, tonsillectomy should be performed 
as soon as the patient is well enough. Removing the 
cause at an early stage makes the reoccurrence of an 
acute nephritis and the transition to a chronic form 
less likely. 

Treatment of acute nephritis by nephrotomy or by 
renal decapsulation has been practiced by some, espe- 
cially in those cases in which there is an abundance of 
lumbar pain and not very severe urinary symptoms. 
These operations have in some cases caused relief of 
symptoms, but should be tried as a last resort. The 
resulting scar tissue as it contracts may of itself 
aggravate conditions, especially if a chronic interstitial 
nephritis should ensue. 

As many cases of acute nephritis arc due to bacterial 
infections the question of the use of vaccines arises. 
Vaccines as yet have not proved to be of any 
assistance in the treatment of nephritis in the acute, 
subacute or chronic stages. 



ACUTE NEPHRITIS IN CHILDREN 297 

ACUTE NEPHRITIS IX CHILDREN 

Renault and Siguret {Annals de Med. et Chir. 
Infant., 1914, April 1, xviii, p. 240), in a study of 
acute nephritis in children, think that bed rest and 
an exclusive milk diet are all that is needed in mild 
cases. When symptoms develop showing that the 
kidneys are becoming less permeable to salt and urea, 
diuresis should be promoted and the congestion in the 
kidney reduced by dry cupping, repeatedly applied in 
Petit's triangle. In the severe cases and with older 
children venesection is sometimes preferable, or wet 
cupping in the lumbar region or leeches to each kidney. 
Moist heat to the chest is often effectual in relieving 
congestion of the kidneys ; it is left in place for fifteen 
or twenty minutes, repeated every three or four hours. 
They advise against revulsion by mustard pastes, etc., 
but have often found useful in the threatening cases 
a full bath at 38 C. for fifteen minutes when there 
were no contraindications on the part of the heart. 
A wet cloth should be kept on the head during the bath . 

Drugs to act on the kidneys are too much of a 
strain for them ; diuresis is best promoted by reducing 
intake of salt and of water. If this is not enough, a 
cold enema might be given every hour, and decoctions 
of cherry stalks, or grape juice in small quantities, are 
often useful adjuvants. Calcium chlorid may help; 
0.2 gm. a day for each year of age, but if it does not 
benefit promptly it should be dropped after a few 
days. Nothing but sugars can be given to promote 
elimination of nitrogen, they say, suggesting 10 to 50 
gm. of lactose in the beverages during the day. Also 
subcutaneous or intravenous injection of 200 or 250 
c.c. of a 45 per thousand solution of glucose. The 
bowels and the skin should be stimulated, but they say 
that calomel and pilocarpin are directly contra- 
indicated. 

Nothing but water, and little of that, should be 
allowed the first two days, then unsalted gruels, grad- 
ually adding a little milk, finally giving nothing but 
milk, and no more than 1.5 liter in the twenty-four 
hours, and always warm, sweetened or not as desired, 
fractioned every three hours from 8 a. m. to 8 p. m. 



298 CHRONIC NEPHRITIS 

The mouth should be rinsed out afterward with an 
alkaline fluid each time. After a time other food can 
be added, but always without salt and with minimal 
nitrogen. If there is no sign of edema by the end of 
a month, a little salt can be allowed. Other important 
elements in treatment are repose in bed, constant 
warmth and scrupulous disinfection of the throat and 
nose every day. In case of convulsions lumbar punc- 
ture may prove useful. 

CHRONIC NEPHRITIS 

Chronic nephritis, Bright's disease, or as it is some- 
times called, cardio-vascular-renal disease, is appar- 
ently increasing in frequency in this country. Its 
treatment, both active and prophylactic, is naturally 
important. Patients suffering from this disease 
usually first consult a physician complaining of the 
symptoms that are usually associated with high blood 
pressure. The physician should then analyze the 
case to find out the fundamental cause of the trouble. 
In some of the cases there is a history of a previous 
acute nephritis, of acute inflammatory rheumatism, 
there may be an old heart lesion or some other point 
in the history that makes the solving of the problem 
relatively simple. In the majority of the cases, how- 
ever, this is not the case and a physical examination 
reveals nothing but a slightly enlarged heart with 
perhaps a little dilatation of the arch of the aorta and 
a slight edema of the feet. Urinalysis may reveal 
nothing, but on repeated examinations the urine will 
be found to be of low specific gravity and occasionally 
to contain casts and a trace of albumin. The blood 
pressure will be found to range from 170 to 200. In 
these cases a careful search for a chronic focus of 
infection must be made. This is usually found in the 
tonsils, teeth, sinuses, or gallbladder. This focus of 
infection must be removed as the toxemia resulting 
from it is probably the cause of the high blood pres- 
sure. If the hyperarterial tension has not been of too 
long standing the removal of the focus will cause an 
almost immediate reduction in blood pressure and a 
complete cessation of symptoms, 



CARDIAC COMPENSATION IN NEPHRITIS 299 

In the cases in which there is an old organic heart 
trouble this must be treated primarily, and as the 
heart condition improves so does the kidney trouble. 
The best treatment for these cases is rest in bed on 
restricted liquids and a soft meat-free salt-free diet. 
In the more severe cases the Karell management is 
most efficacious. The Karell treatment consists of 
rest in bed and a light diet of milk and eggs. The 
fluid is limited to 1 y 2 pints per day. At first this is 
given, for two or three days, as milk only, 6 to 7 
ounces at 8 a. m., and 4 to 8 p. m. This is the most 
trying part of the method. Then 1 egg is given at 
10 a. m. and a biscuit at 6 p. m. for a couple of days. 
Then 2 eggs with bread, and a little minced meat are 
allowed. In twelve days the patient returns to a 
careful ordinary diet, the fluid being still kept down 
to \y 2 pints, but not necessarily milk only. This 
method is said to be indicated for weak hearts for 
which digitalis is less appropriate. About the third 
day diuresis sets in for a short time, the dyspnea is 
relieved, the pulse improves, and the edema subsides. 
Elimination through the gastro-intestinal tract should 
be promoted by the use of calomel (3-5 gr. at night) 
and salines in the morning. If the patient is showing 
signs of intoxication, and is strong enough, hot air 
sweats may be beneficial. Venesection may also be 
indicated in such cases and by relieving the heart and 
removing toxins often causes marked improvement. 
The same management is applicable to the cases in 
which the kidney is the most affected organ. 

The most important item in the treatment of chronic 
nephritis, according to Elliott {Jour. A. M. A., Nov. 
21, 1914, p. 1878), is the preservation of cardiac com- 
pensation. The high blood-pressure and cardiac 
hypertrophy of chronic nephritis constitute a com- 
pensatory mechanism enabling the kidneys to main- 
tain adequate function. They consequently are essen- 
tial to the preservation of life and should be protected 
by every hygienic and dietetic safeguard. High blood- 
pressure should not be made the object of direct thera- 
peutic attack. Nitrites should be reserved for emer- 
gency use to combat such developments as angina, 



300 ARTERIOSCLEROSIS IN NEPHRITIS 

cardiac asthma, etc. The appearance of dropsy in 
primary chronic nephritis almost invariably signifies 
the advent of cardiac failure. At this stage the 
digitalis bodies become the mainstay of treatment 
and should not be withheld because the blood-pressure 
is high, as they act just as well or even better with a 
high blood-pressure as with a falling pressure. 

In the cases that are primarily cardiac the use of 
cafifein, digitalis, strophanthus and the other cardiac 
tonics is of great value. The use of theobromin and 
other drugs, the action of which is essentially diuretic, 
should be guarded as in many cases of chronic renal 
disease they do not increase the output of urine and 
act rather as a poison on the system. 

In certain cases of chronic nephritis in which there 
is considerable edema without dilatation of the heart 
the Fischer treatment, as described under acute nephri- 
tis, produces excellent results, but on the whole it 
does not seem to be as efficacious in the chronic as in 
the acute nephritides. 

Another form of chronic nephritis that must be 
considered is that caused by general arteriosclerosis. 
In this form there are two causes for the trouble, 
namely, the injury to the kidney parenchyma from 
the altered blood supply to the kidneys and the toxemia 
arising from the altered metabolism throughout the 
body which is due to impairment of the circulation 
from the arteriosclerosis. In this form the treatment 
must necessarily be purely palliative, as the cause can 
not be removed. These cases are usually, weak, 
anemic and poorly nourished and consequently the 
sweats and venesection can not be used. The Karell 
management is the best to use in severe cases of this 
type, but ordinarily restriction of liquids to one quart 
or so, a meat-free diet and free catharsis suffices to 
keep these cases comfortable. In these cases diuretics 
and cardiac stimulants must be used with great care 
and in many of them are contraindicated. 

In those cases of nephritis in which there is 
amyloidosis the treatment should be primarily of the 
causative condition as the kidney condition is secondary 
to it. 



GENERAL TREATMENT OF NEPHRITIS 301 

As to the treatment of the cases of long standing 
cardio-vascular-renal disease that are to all appear- 
ances in excellent health, but have a constant high 
blood-pressure and much of the time have albumin 
or casts in the urine. Most of these cases may be 
kept very comfortable and the blood-pressure kept 
reasonably low if they will diet carefully and exercise 
only moderately. Such individuals should avoid meats, 
especially the red meats. Coffee, tea, alcohol, rich 
spiced foods and tobacco should not be used at all. 
The diet then should consist of fruits, cereals, vege- 
tables, eggs, milk, cream, butter, and in most cases 
such meats as chicken, turkey, lamb and fish may be 
allowed once a day. Shell fish may be used in 
moderation. 

These patients may exercise moderately, and indeed 
it is best for them to get a definite amount of out-of- 
door exercise. Walking is the best form and golf in 
moderation may be allotted to some. Whatever form 
of exercise is taken, it should be begun gradually and 
increased slowly. While this is being done the patient 
should be frequently examined by the physician to 
make sure that he is not overdoing. 

As to the massage and bath treatment of nephritis, 
when regulated by a physician who is in close touch 
with the patient's general condition, such treatment 
as is given at many places abroad and in this country 
is excellent. However, unless controlled by a physi- 
cian, such treatment may do a great deal of harm. 
Massage is only a form of exercise and if overdone 
may do as much harm as too much exercise of any 
other sort. Baths are quite enervating and fatiguing 
even to a healthy individual who is not accustomed 
to them, and so to the nephritic with his lowered 
vitality may be a source of great danger. 

As to the mineral waters of various sorts which 
are extensively advertised for use in nephritis, these 
derive what value they possess from their mild cathar- 
tic and diuretic action. In those cases in which the 
excretion of water is abundant, the use of these waters 
may be of assistance as they promote elimination. 
They have no specific action as is claimed for many 



302 UREMIA 

of them and should not be used in those cases in 
which the excretion of water is diminished. When 
limitation of liquid intake is necessary the liquids taken 
should be restricted to milk, cream soups, fruit juices, 
etc., which are nourishing and as efficacious as diure- 
tics and laxatives as the mineral waters, are more 
pleasant to take and more quenching to the thirst. 

When it is possible, patients suffering from chronic 
nephritis may spend as much time as possible in warm 
climates, as warm weather promotes elimination 
through the skin. Furthermore, by causing a super- 
ficial vasoconstriction cold tends to increase the ten- 
sion in the deeper vessels and so increase the possi- 
bility of cerebral hemorrhage or hemorrhage from 
other vessels. Angina pectoris, which may be a com- 
plicating factor in many of these cases of hyperarterial 
tension, is often subsequent in appearance to sudden 
exposure to cold. 

UREMIA 

In uremic patients there is a severe toxemia due to 
renal insufficiency. When the patient is quiet, the 
relief of the toxemia is the chief requirement except 
such general supportive measures as may prove neces- 
sary. This toxemia has usually been treated by the 
promotion of elimination through the skin by sweats, 
through the intestines by free catharsis and also by 
venesection. The diuretics are generally of little use 
in treating these conditions. Fischer's solution 
administered intravenously or per rectum has proved 
to be one of the best, if not the best, methods of 
promoting elimination through the kidneys in these 
cases. The general symptoms are also greatly relieved, 
even when sweating and venesection are not used. 
Some of the most striking results obtained by the use 
of Fischer's solution have been in cases in which 
there was insufficient excretion of urine and a con- 
sequent uremic condition with no clinically demon- 
strable anasarca. 

In those cases of uremia in which the patient is 
extremely restless, and also in those in which there 
are convulsions, the above eliminative treatment must 
be used, and in addition the patient must be quieted. 






CYSTINURIA 303 

In the first place the usual methods of restraining a 
patient in bed must be practiced. Windows should be 
protected to prevent accidents ; all instruments with 
which injury might be done to attendants or to the 
patient should be kept out of reach. Bromids may be 
given in enemas in doses of twenty to thirty grains 
in place of the salt of the Fischer's solution. If the 
patient will take them they may be given by mouth. 
Chloral may also be administered either by mouth or 
per rectum. In the more severe cases it is necessary 
to use opiates and sometimes even chloroform to 
quiet the convulsions. Many of the cases of uremia, 
however, proceed to a fatal termination in spite of all 
that may be done. At necropsy a complicating broncho- 
pneumonia or hypostatic pneumonia is often found 
which undoubtedly has much to do with the fatal 
termination of the disease in these individuals. 

CYSTINURIA 

Cystinuria may be classed among the rarities of 
medical practice. However, the perversion of meta- 
bolism whereby cystin, one of the amino-acid frag- 
ments of the protein molecule, is not destroyed in 
the body as it is in a normal person, is not so uncom- 
mon as statistics might lead one to believe. As the 
metabolic disorder may exist for very long periods 
without revealing itself by any easily detected symp- 
tom other than the presence of the unutilized cystin in 
the urine, the discovery of the cases becomes more or 
less fortuitous. Only when urinary concretions arise 
to direct attention to their cause, or when the presence 
of cystin is detected by chance in a routine examina- 
tion of the urine, does the anomaly come to the knowl- 
edge of those who are interested in its cause and 
treatment. 

From the point of view of the patient the chief prob- 
lem in connection with cystinuria is either to decrease 
the output of cystin or to increase its solubility in the 
urine — or both — with the aim of avoiding the impend- 
ing danger of calculi. The pronounced insolubility of 
cystin in urine of the usual reaction makes the pos- 
sibility of attacks of "kidney colic" and related conse- 
quences an ever-present one. It has long been known 



r 



304 ALKALIES IN CYSTINURIA 

that the output of cystin can be decreased by a diminu- 
tion of the metabolism of its mother-substance, pro- 
tein. In the entire absence of any intake of albu- 
minous foods, the urinary excretion of cystin is 
reduced to an endogenous level, represented in an 
illustrative case in the literature by 78 mg. a day. 

Klemperer and Jacoby (Therap. der Gegenw., 1914, 
lv., p. 101) studied the results of alkali administra- 
tion in such a case. They found that the deposited 
cystin sediment promptly decreased in amount and 
soon completely disappeared from the urine following 
the daily ingestion of from 6 to 10 gm. of sodium 
bicarbonate. From the point of view of preventing 
the precipitation of cystin and consequent formation 
of calculi, this treatment was evidently successful. 
Incidentally, it further developed that even dissolved 
cystin entirely disappeared from the urine as the result 
of the alkali therapy. 



DISEASES OF METABOLISM 



DIABETES MELLITUS 

According to Osborne, while a frequently occurring 
glycosuria may be a danger signal as a forerunner of 
the real disease of diabetes mellitus, still, if the sugar 
can be made to disappear from the urine by a change in 
the diet, that disease is not present, but the presence 
of sugar in the urine shows that there is an insuffi- 
ciency of the organs taking part in the glycogenic 
function, viz., the pancreas, suprarenals or liver. An 
insufficiency or an improperly correlated activity of 
any one of these three organs may cause sugar to 
appear in the urine. A temporary glycosuria may be 
caused by "phosphoric, lactic and hydrochloric acids, 
phosphorus, arsenic, and by carbonic oxid poisoning." 
Glycosuria may also occur as a complicating distur- 
bance in Graves' disease, exophthalmic goiter, and dur- 
ing the administration of thyroid extract, showing that 
too much thyroid stuff in the circulation can cause 
glycosuria. Various disturbances in the brain can 
cause, reflexly, glycosuria which will disappear if the 
disturbance is removed. 

In certain cases glycosuria is due to the fact that the 
kidneys are unable to retain the sugar present in the 
blood. This is termed renal diabetes. 

The diagnosis of diabetes is based on the finding of 
sugar in the urine. Of recent years, an examination of 
the blood as to the amount of sugar present in it is 
also being made thus ruling out renal glycosuria. In 
diabetes the sugar persists and increases under inade- 
quate treatment. Even under the best regulated treat- 
ment, however, a trace of sugar may remain or reap- 
pear at intervals, in the urine. 

THE DIET IN DIABETES 

In regulating the diet it is important not only to 
exclude sugar and sugar forming material but to 
reduce the total quantity of food so as not to tax 



306 DIET IN DIABETES 

unduly the metabolism of the patient. According to 
Allen, who has made a scientific and elaborate study 
of the subject, the first step is to fast till glycosuria 
ceases, and then for twenty-four to forty-eight hours 
longer. 

When the fasting patient has been free from glyco- 
suria for twenty-four to forty-eight hours, the next step 
is to begin feeding very slowly and cautiously. There 
need not be a fixed program. It is desirable to indi- 
vidualize the diet to suit the needs of different patients. 
The one requirement is that the patient must remain 
free from both glycosuria and acidosis. Any trace of 
sugar is the signal for a fast day, with or without alco- 
hol. The original fast, to clear up the urine in the 
first place, may be anything from two to ten days, but 
after that no fast need be longer than one day. The 
things to be considered in the diet are carbohydrate, 
protein, fat and bulk. Frequently the first thing given 
after the fast is carbohydrate. No distinction is neces- 
sary between different forms of starch, but there are 
advantages in using vegetables. The first day after 
fasting, the only food may be 200 gm. of vegetables 
of the 5 and 6 per cent, classes. This is increased day 
by day until a trace of glycosuria appears, which is 
checked by a fast day. The purpose of such a program 
is to learn the carbohydrate tolerance and to clear up 
the last traces of acidosis. Falta (Abstr. Jour. 
A. M. A., Feb. 14, 1914, p. 580) explains the reasons 
for his practical conclusions that the diet of diabetics 
should be predominantly boiled cereals. When baked, 
the grains are broken up in a different way and absorp- 
tion proceeds under conditions that do harm. In 
gruels, porridges and soups, however, all the cereals 
are available and also rice, tapioca, potato, corn and 
millet, alone or in combination. He thinks that the 
greater consumption of meat is possibly responsible to 
a certain extent for the increasing frequency of dia- 
betes. When there is a predisposition to diabetes, the 
abuse of meat should be warned against ; it is possible 
that a strict vegetarian diet, with cereals boiled instead 
of baked, might help to ward off the disease better 
than the restrictions hitherto in vogue. Knerr's 
(Abstr. Jour. A. M. A. } March 13, 1915, p. 942) pro- 



ALLEN DIET IN DIABETES 307 

cedure is to put the patient to bed and allow him noth- 
ing whatever except a dram of raw cornstarch stirred 
in a glass of warm water every two hours. The result 
is most gratifying. Both sugar and acidosis decrease 
gradually. The raw starch serves two purposes : It 
supplies considerable nourishment and it prevents aci- 
dosis, so there is no danger of coma and no need of 
alkaline dosage, and the patient suffers none of the 
distress of the rigid starvation regime. All wines and 
some whiskies and brandies contain some sugar, so 
Knerr prefers pure alcohol if any is to be given at all. 
Its only advantage is to modify the taste of the raw 
beaten tgg. 

After the carbohydrate period, according to Allen, 
or sometimes in place of it, protein is given. On the 
first day perhaps one or two eggs are given, and noth- 
ing else. More protein, generally as eggs and meat, 
is added day by day, until the patient either shows 
glycosuria or reaches a safe protein ration. The pur- 
pose here is to learn the protein tolerance, and to 
cover protein loss as quickly as possible. Fat is some- 
what less urgently needed, except in very weak and 
emaciated patients ; it can be added gradually, as con- 
ditions seem to indicate. An element of bulk in the 
diet is necessary to give the comfortable feeling of ful- 
ness and to prevent constipation. This is the great 
advantage of green vegetables. When they are fed 
raw, or cooked in steam, or boiled and evaporated so 
that no water is thrown away, they contain a definite 
quantity of carbohydrate besides valuable salts ; and 
this is the only form of carbohydrate that patients 
thus treated ordinarily receive. Some cases are so 
severe that even green vegetables cannot be tolerated. 
Under these conditions the vegetables may be boiled 
through three waters, throwing away all the water. 
Nearly all starch is thus removed, and the most severe 
cases generally, take these thrice-cooked vegetables 
gladly and without glycosuria. 

One result of the initial program described is the 
loss of weight. The attempt to put on weight, Allen 
says, is one of the surest ways of bringing back all the 
symptoms and sending the patient down hill. It is 
probably one of the chief causes of past failures in 



308 ACIDOSIS IN DIABETES 

treating severe diabetes. In the severe cases it is found 
necessary to restrict all classes of. food, and to test the 
tolerance of each patient for each particular class. 
Carbohydrate is given if possible, but is kept safely 
below the limit of tolerance. Protein must be kept 
fairly low, sometimes very low. With a dangerously 
low protein tolerance the working rule has been to 
exclude all carbohydrate, then feed as much protein 
as is possible without glycosuria. 

ACIDOSIS 

Ever since the danger of acidosis has been recog- 
nized and the likelihood of acidosis being caused by a 
sugar and carbohydrate-free diet in this disease, physi- 
cians have been constantly on the alert to recognize 
this condition by a study of the urine. The indicator 
of danger has been considered to be the finding of dia- 
cetic acid in the urine. This is of ready determination 
by a ferric chlorid solution added to the urine causing 
the development of a red or crimson color. The pre- 
cipitate of phosphate of iron thus produced may 
obscure the tint characteristic of the reaction. The 
urine should then be filtered and an excess of ferric 
chlorid solution added to the filtrate. It has been 
found, however, that this reaction could be pres- 
ent and still not be a positive indication of the amount 
of beta-oxybutyric acid that is in the urine or the 
nearness of an actual toxic acidosis. The determina- 
tion of the beta-oxybutyric acid is tedious. The same 
is true, more or less, of acetone and ammonia that may 
be present in the urine. Therefore the tests must be 
made in the laboratory and should be made frequently 
when a diabetic patient's diet is being gradually reduced 
to pure proteid and fats. By such careful examina- 
tion it has been lately learned that the presence of 
these acids in the urine is not necessarily an indication 
that the diet must become more liberal or that starch 
should be immediately given. Of course if symptoms 
of diabetic coma arc present very large amounts of 
alkalies must be administered and starch in liberal 
quantities must be immediately allowed. 

If coma is considered to be imminent, carbohydrates 
and alkalies should be given in large amount, and per- 



COMPLICATIONS IN DIABETES 309 

haps no alkali is better than the bicarbonate of sodium 
in two-gram doses (30 grains), in water, every hour 
for several doses. If the danger is past the diet should 
be liberal, with the free use of starches, until the urine 
is again free from diacetic acid. However, when coma 
is pending it is often impossible to prevent its occur- 
rence, and the treatment of such a condition is the 
prevention, viz., the patient should receive, if seen in 
time, such a diet as to minimize the occurrence of 
coma. Alkalies may be given intravenously in the 
form of the well known Fischer solution which is also 
given per rectum by the continuous drip method. 

COMPLICATIONS AND SEQUELAE 

It should be remembered that a generalized and per- 
sistent furunculosis may be an unpleasant accompani- 
ment of diabetes. Diabetic gangrene is another con- 
dition which may appear in the course of this disease 
and necessitate operation. Operations on diabetics are 
notoriously dangerous and usually undertaken only 
when deemed a life-saving measure. 

Addis (Jour. A. M. A., April 3, 1915, p. 1130) con- 
siders the necessary preparation of diabetics for opera- 
tion. One method of preparing diabetic patients for 
operation is to give them a sugar and starch-free diet. 
This is a useless procedure, according to Addis, 
because, although it may reduce the degree of hyper- 
glycemia and the amount of sugar in the urine, it will 
not lessen any of the risks of operation; it is danger- 
ous, since it increases the chances of the onset of dia- 
betic coma. When operation is not immediately neces- 
sary, and especially in those cases in which the decision 
as to whether or not an operation shall be performed 
rests largely on the question as to how much danger 
would be run by the patient after the operation because 
of his diabetic condition, it would be a great advantage 
to have some objective data to supplement the facts 
relative to this point, which can be gained by clinical 
observation. The quantity of sugar in the urine is no 
aid in this respect, for the special danger to life is the 
failure, not of the sugar, but of the fatty acid metabo- 
lism. The coma in which diabetic patients die after 
operation is, often at least, accompanied by the excre- 



310 DIABETES INSIPIDUS 

tion in the urine of large amounts of unoxidized fatty 
acids, and there is good reason for believing that the 
condition is due to poisoning by these acids. The ina- 
bility of the kidneys to excrete large amounts of fatty 
acids is a factor in the production of diabetic coma. 
The giving of alkali helps the kidneys in this work. 
Before operation, therefore, it is important to give 
alkali until the urine becomes alkaline, and to maintain 
if possible this alkaline reaction after operation. 
Neither success in inducing a storage of glycogen in 
the body before operation, nor in keeping the urine 
alkaline is an absolute barrier against diabetic coma. 
They are only palliative measures. All those circum- 
stances which unite together to produce shock are fac- 
tors which act as exciting causes of the condition 
known as diabetic coma. It is possible to mitigate the 
action of these agencies by the application of the prin- 
ciples of "anoci association/' 

DIABETES INSIPIDUS 

This condition is recognized by the excretion of 
large quantities of non-sugar-containing urine, not: 
directly due to an excessive intake of fluids (polydip- 
sia). Connected etiologically with this condition the 
following have been mentioned : cerebral irritation, dis- 
eases and injuries of the cerebrum, diseases of the 
pituitary body, and finally, a primary cause in the 
kidney. 

The diagnosis of the cause of diabetes insipidus hav- 
ing been made, the treatment may be aimed more or 
less successfully to cure the condition, or to prevent the 
operation of the cause. A simple polyuria from over- 
drinking can, of course, be easily prevented. Nervous 
causes may be modified if there is not actually some 
pathologic condition in the brain. If the blood-pressure 
is high, the lowering of it by proper baths, massage, 
physical exercise, change to a warm climate, diet, or by 
vasodilators will prevent it. Polyuria may, however, 
occur with low blood-pressure causing perhaps some 
disturbance of the brain, as theoretically low blood- 
pressure should not cause diabetes insipidus. Such 
instances may be helped by the vasoconstrictor drugs, 
and especially by ergot. It is possible that this efifect 



GOUT 311 

of ergot is due to its action in preventing cerebral 
irritation, cerebral congestion, and possibly the slight 
cerebral exudate that may occur. 

GOUT 

The etiology of gout is unknown. It is generally 
believed to be connected in some way with an imper- 
fect or deranged metabolism of purins. Among various 
predisposing causes are heredity, alcohol, habits, over- 
eating, etc. 

Among the prominent symptoms are chalky deposits, 
tophi in the ears, gouty joints, with accompanying 
shooting pains, increased arterial tension and gastro- 
intestinal upsets. 

The individual joints may be treated, as has been 
mentioned under arthritis, by rest, moist sedative 
fomentations, morphin to stop pain, etc. As internal 
medication the salicylates, colchicum, atophan and 
novatophan have been especially recommended. The 
diet in gout should logically be purin-free. Fish and 
flesh of all kinds should be prohibited. Alcoholic 
stimulants which increase the formation of uric acid 
should not be allowed. Rich soups, fried foods, 
radishes, asparagus, tomatoes and dried beans are best 
omitted from the diet as are preserves, candies, pies, 
pastries, etc. 

The patient should take a moderate amount of plain 
nutritious foods. Eggs, fresh vegetables, except such 
as have been excluded, various cereals, and fresh 
fruits and milk may be freely eaten. Meats, oysters, 
etc., may at times be taken with caution. 

OBESITY 

Obesity is a condition accompanied by the accumu- 
lation of extraordinary, therefore pathologic quanti- 
ties of fat. Unless causing definite functional dis- 
turbance no treatment is necessary. A reference to 
the table of height and weight at varying ages in the 
front section of the book will indicate what is normal. 

The treatment of obesity must include primarily a 
regulation of the diet to prevent the feeding of excess 
food over what the body can utilize and a regulation 
of body work to produce a demand for energy giving 
constituents. 



312 DIET IN OBESITY 

DIET 

The number of diets which have been offered for 
obese persons is almost legion. Certain general prin- 
ciples must be observed. An average of several of 
the best known diets is as follows: Protein, 140 gms., 
fat, 40 gms., carbohydrates, 90 gms., calories, 1,320. 
It can be taken as a matter of fact that most people 
eat too much. The appetite may be better controlled 
and hunger appeased by small quantities of food 
taken frequently. Depressing of the appetite is com- 
monly advised and may be accomplished in several 
ways, notably by long chewing of the food and limita- 
tion of the variety. Sternberg believes that drugs 
should be used to prevent hunger and reduce the 
appetite. He has found preparations of iodin particu- 
larly useful for this purpose. The anesthetization of 
the mucous membrane of the stomach also aids in 
warding away hunger. Peppermint lozenges and 
menthol tablets reduce the sensibility of the mucosa 
and minute doses of camphor seem to produce a feel- 
ing of fulness. Coffee taken early in the meal has 
long been advocated by Sternberg as it reduces appetite 
and lessens the usual desire of the overcorpulent 
to sleep. 

Friedenwald and Ruhrah give the following general 
directions : Avoid sugars and starchy food and take 
little or no fatty food. Eat sparingly and take but 
little fluid — and that apart from meals. Obese persons 
may eat small quantities of chicken, beef, oyster, bouil- 
lon or clam soups ; meat once daily consisting of beef, 
lean, raw, scraped, boiled or broiled ; steak, broiled ; 
mutton, roasted ; chops, broiled ; chicken, boiled or 
broiled. Eggs should be eaten only soft boiled or 
poached. Of fish the following may be taken : oysters, 
raw ; mackerel, rock or trout, boiled. Vegetables are 
best taken mashed and strained. Of bread, but a 
small quantity should be allowed and then only in 
the form of stale wheat bread, zwieback, toast, graham 
or gluten bread. The following fruits, all of which 
arc acid, may be recommended : lemons, oranges, raw 
apples, grapes, raw peaches, berries and cherries. 
Water should be taken sparingly at meal times. Tea 
and coffee may be taken but without sugar or milk. 



EXERCISE IN OBESITY 313 

Mineral waters ordinarily may be allowed in quantity 
sufficient to assuage thirst without causing disagree- 
able symptoms. 

The following articles of diet should not be taken : 
rich soups, fried foods, pork, veal, stews, hashes, 
corned meat, potted meat, liver, kidney, duck, goose, 
sausage, crabs, lobsters, preserved fish, smoked or 
salted fish, salmon, bluefish, salt mackerel, herring, 
hominy, oatmeal, rice, puddings, sardines, celery, pota- 
toes, turnips, carrots, parsnips, sweet potatoes, beets, 
hot bread or cakes, nuts, candies, pies, pastry, alcoholic 
stimulants. 

HYDROTHERAPY 

The use of cold baths in the treatment of obesity as 
well as special forms of hydrotherapy is generally well 
known. Besides improving the skin and aiding the 
circulation, it seems likely that such baths also accel- 
erate the loss of fat. 

EXERCISE 

In the presence of circulatory disorders the prescrip- 
tion of exercise must be cautious. Otherwise it is a 
valuable aid in producing a loss of weight. 

Walking and horseback riding, swimming and 
graded calisthenics, may be of value. Golf and tennis 
may likewise be indicated if the physician thinks 
proper. 

Massage, if given vigorously and accompanied by 
passive motion sometimes produces marked results, 
especially in those of markedly sedentary habits. 

The Zander apparatus produces passive mechanical 
exercise. Besides such machines others combining 
weight lifting, pushing, pulling and stretching move- 
ments may be employed in suitable cases. 

Bergonie has designed an apparatus which acts on 
the essential principle that the w^hole musculature of 
the body shall be stimulated by electric excitation to 
painless, rhythmic, passive contractions. Several 
observers have reported marked permanent losses in 
weight under such treatment. It has also been said 
that the method is a severe one and not to be continued 
too long at a single sitting because of the danger to 
the heart musculature. 



314 MEDICINAL TREATMENT OF OBESITY 

MEDICINAL TREATMENT 

Obesity cures of a fraudulent nature are legion. 
In most instances they are either dangerous or worth- 
less, or both. Thyroid extract has been and still is the 
basis of many so-called "fat reducers. " Lemon juice 
has had its day and numerous iodid preparations have 
been exploited. Bladderwrack, a form of seaweed, 
has likewise had a peculiar vogue. Among a number 
of obesity cure fakes which have been included in 
a pamphlet issued by The Journal of the American 
Medical Association may be mentioned: Marjory 
Hamilton's Obesity Cure, Texas Guinan, Turner Tri- 
plex System of Weight Reduction, Berledets, Every 
Woman's Flesh Reducer, "Get Slim," Kellogg's Safe 
Fat Reducer, Rengo, Marmola and Louisenbad Reduc- 
tion Salt. 

Von Noorden believes there is an endogenous con- 
stitutional type of obesity which he regards as trace- 
able to thyroid functioning. Congenital or acquired 
weakness or degeneration of the thyroid may induce 
the obesity directly or the thyroid may become a factor 
in the obesity only secondarily, as in case of pancreas 
disease (demonstrated only experimentally as yet) ; 
disease in the ovaries or testicle (deficiency of the 
interstitial substance) ; disease in the pituitary body 
(adipose-genital dystrophy) ; disease in the pineal 
gland or thymus (both dubious). There may also be a 
combination of both the exogenous and endogenous 
type, especially in the young. 

Throughout the endogenous forms, abnormal thyroid 
functioning is common to all, and treatment of consti- 
tutional obesity must be based on thyroid treatment. 
It is unquestionable now that the reliance on thyroid 
treatment is increasing, the dread of it diminishing. 
The dangers from thyroid treatment are just as 
great as ever, but we know better how to watch 
out for them and guard against them. He adds 
that even in cases amenable to systematic dietetic 
measures alone, the prolonged restriction of the diet 
seems to him more of an evil than a course of thyroid 
treatment. With this the diet need not be so strictly 
regulated and the effect of the thyroid treatment is 
often permanent, so that the patients can eat like 



MEDICINAL TREATMENT OF OBESITY 315 

other people afterward without bringing back the 
obesity. During the thyroid course ample provision 
of albumin should be ensured. The urine should be 
examined often for sugar. The tendency to acceler- 
ation of the heart action and drop in blood pressure 
can be warded off by daily small doses of some 
digitalis preparation. The thyroid seems to lead to an 
increase of oxygen consumption and carbon dioxid 
excretion. If used it may be given in doses of one 
to two grains twice or three times daily and increased 
only very cautiously. 



DISTURBANCES OF THE HEART 



Of late years the disturbances of the heart are 
beginning to assume a more prominent place in the 
list of causes of death, so that perhaps only tubercu- 
losis and kidney disturbances are more prominent. It 
has been said that although the majority of sudden 
deaths are due to a cardiac cause, there are few 
chronic diseases so amenable to treatment and so 
compatible with long life and comfort, if judiciously 
handled, as cardiac cases. Of late years also there 
have come into prominence numerous delicate methods 
of examining the heart's functioning, testing its rate 
and its rhythm. These newer methods have pointed 
the way toward efficacious therapeutic measures. 

THE PREVENTION OF CARDIAC DISTURBANCES 

Although we shall consider under each heading the 
various elements in the etiology, it may be worth while 
here to take up some of the more general factors 
which produce cardiac disturbances. 

Recent studies of focal infections have shown that 
a tonsillitis, an abscessed tooth, etc. may be the origin 
from which spring germs that later may cause an 
endocarditis, or valvular infection. 

Patients are likely to manifest a desire to become 
active too soon after a serious illness or a surgical 
operation. The physician or surgeon should not sub- 
mit his patient to such strenuous cardiac tests. If 
the patient manifests a marked rapidity in the heart 
rate on first sitting up in bed, cautious consideration 
should be given to his symptomatology before allow- 
ing him to arise. 

Schumacher and Middleton have called attention 
to the serious cardiac disturbances in young men who 
have indulged too vigorously in modern athletic 
competition. 



TREATMENT OF PERICARDITIS 317 

ACUTE PERICARDITIS 
Pericarditis is almost invariably a secondary con- 
dition, the most frequent infectious cause being 
rheumatism, others being cerebrospinal fever, acute 
miliary tuberculosis, pneumonia and sepsis. Acci- 
dental causes are traumatism, and an adjacent inflam- 
mation of the pleura. Pericarditis may also be ter- 
minal in nephritis, adjacent abscesses, cancer and 
other new growths. The prevention of the disease 
must then be related to the removal of the cause. 

TREATMENT 

Of primary importance in the treatment of peri- 
carditis is rest. The patient should have absolute 
rest. He should not be allowed to sit up in bed even 
to eat or attend to the calls of nature. He should 
have no visitors. Anything that increases the heart 
beat increases the irritation of the inflamed surfaces 
of the pericardium. 

Just what can be done locally or generally to com- 
bat the inflammation actively must depend on the 
cause. When the inflammation occurs as a complica- 
tion of acute rheumatism, it has been suggested that 
salicylates, which do not inhibit rheumatism and may 
be depressant to the heart, should be stopped if they 
are being administered ; but if the salicylates are 
apparently improving the inflammation in the joints, 
pericarditis would not contra-indicate their continued 
use. Except in large doses, salicylates probably do 
not depress the heart. In pericarditis it is perhaps 
well always to administer an alkali in some form unless 
otherwise contra-indicated, whether the cause is rheu- 
matism or not. A diminished alkalinity of the blood 
would always increase the likelihood of an augmented 
amount of pericardial or endocardial inflammation. 
Alkalies may be freely given. It is possible that one 
of the reasons why pericarditis or endocarditis occurs 
so frequently in serious prolonged fevers is that the 
patient has not eaten enough cereals or other carbo- 
hydrates, and the system has become more or less 
endangered by acidosis. In other w r ords, carbohydrate 
starvation is inexcusable with our present understand- 
ing of the danger from acidemia and even from a 
diminished amount of alkalies in the blood. 



318 EXUDATE IN PERICARDITIS 

The causes of pericarditis being so varied, any anti- 
toxin treatment or any vaccine treatment could be 
indicated only if the cause of the inflammation ren- 
dered the serum or vaccine advisable. 

The most valuable local treatment is cold, which 
may be applied either in the form of an ice-bag or by 
a small coil through which ice-water is caused to flow 
by siphonage. Cold may be applied more or less con- 
tinuously, depending on the sensations of the patient. 
The bag or ice-cap must not be overfilled and must 
not be heavy, as the patient often cannot stand pressure 
over the pericardium. Sometimes the relief from 
pain and the diminution of the number of the heart- 
beats is marked, and from this reason alone the cardiac 
inflammation may be inhibited. If cold applications 
are not tolerated by the patient (and they often are 
not in children) warm applications may be used, such 
as flaxseed poultices, or cloths wrung out of hot water 
and covered with oil-silk, and the pain will often be 
relieved thus. While hot applications would not tend 
to abort the inflammation, they probably do not tend 
to promote it. 

A diminished diet, of small amount at a time, and 
such purging as the patient's strength will allow are 
essential in attempting to curtail the seriousness or 
amount of this inflammation. 

Stopping the Pain. — Nowhere else in the body 
should pain be so speedily combated as when it occurs 
in the region of the heart. Morphin should be admin- 
istered as needed to control the pain. The ice-bag may 
often be used to advantage to obviate the frequent 
need of morphin. If morphin is contra-indicated other 
sedatives may well be employed. Ergot may be used, 
especially if there are cerebral symptoms and if the 
arterial tension is low. It is best administered by 
injection of an aseptic preparation deep into the 
muscles. 

The Exudate. — It is not known how much is to be 
gained by indirect measures tending to prevent exuda- 
tion and hasten resorption of the exudates. However, 
purging, diuresis and local application of blisters have 
been employed for these purposes. The saline purges 
are best employed if the heart is strong. If the circula- 



CONVALESCENCE IN PERICARDITIS 319 

tion is weak, the vegetable purgatives or calomel may 
be employed. 

For diuresis potassium citrate or if the heart muscle 
is in good condition, digitalis, may be employed. 

Small blisters over or around the heart have some- 
times seemed to be of service in hastening resorption 
of exudates. Small doses of sodium iodid 0.2 gm., 
or 3 grains, three times a day, may be given for this 
purpose. 

The intake of food and especially of fluids should 
be decreased but the nutrition of the patient should 
not be allowed to suffer. 

If in spite of all the therapeutic measures sug- 
gested, the fluid increases and the pericardium becomes 
more distended and the heart's action more labored, 
paracentesis must be done. The point where the 
aspirating needle should be inserted into the peri- 
cardium depends somewhat on the conditions in each 
individual case. It is often best to insert an explora- 
tory needle first. This will determine the fluidity and 
character of the exudate. If pus is found, a more 
radical surgical procedure than simple paracentesis 
must be done immediately. The point of puncture for 
aspiration most frequently chosen is in the fourth or 
fifth intercostal space, about an inch to the left of the 
sternal margin. Paracentesis is also often done in 
the region of the normal apex-beat. The position of 
the patient is determined by his dyspnea ; he should 
lie in the position most comfortable for him. The 
fluid should be withdrawn slowly and the pulse care- 
fully watched. The withdrawal of a small amount 
of fluid may later seem to be the starting cause of 
resorption of tne rest of the fluid. On the other hand, 
it often accomplishes nothing but the removal of the 
immediate pressure, the fluid may again accumulate, 
and more radical surgery must be performed. 

Convalescence. — The convalescence should be pro- 
longed as in any other cardiac inflammation. The 
patient should be given more and more nourishing 
food, and the iron tonic may be changed to a capsule 
containing 0.05 gm. of quinin and 0.05 gm. of reduced 
iron, three times a day. 



320 MYOCARDITIS 

It is a question as to when patients convalescent 
from pericarditis should be permitted exercise. It has 
been thought that gentle movements and possibly exer- 
cise, sooner than theoretically justified, might cause 
the heart to beat a little more actively and possibly 
prevent the formation of tight adhesions between the 
two layers of the pericardium. Whether such activity 
of the heart will prevent adhesions is something that 
has not been determined. 

The small doses of sodium iodid, perhaps 0.2 gm. 
(3 grains) two or three times a day, should be con- 
tinued for some time. Iodid in this dosage does no 
harm and may do a great deal of good. 

MYOCARDIAL DISTURBANCES 

The condition of the myocardium or heart muscle 
is often the determining factor as to whether a patient 
shall live or die. If the myocardium be degenerated 
at the end of a long severe illness, a too rapid attempt 
at a return to ordinary activities may bring about a 
dilatation of the heart which is itself responsible for 
sudden death or prolonged disability. 

Acute Myocarditis 

Practically all acute infections cause more or less 
myocarditis. It is exceedingly rare indeed that an 
endocarditis occurs without an accompanying myo- 
carditis. The condition is not diagnosed until a sudden 
acute dilation calls for emergency treatment. 

The symptoms are often indefinite. As acute myo- 
carditis develops the apex beat is less positive, less 
accentuated and later diffuse and feeblc % . The closure 
of the aortic valve is less typically sharp; showing that 
the blood vessels are not so thoroughly filled. The 
peripheral circulation may not be active, the blood 
pressure falls, and the heart becomes more rapid, 
especially after exertion. 

The prevention of this condition must be rest. 
Patients should not be allowed to make too rapid a 
convalescence after an infectious disease, a labor, or 
a surgical Operation. Such cardiac tonics as digitalis 
should not be riven ; fluids should be diminished. The 



TREATMENT OF MYOCARDITIS 321 

circulation should be stimulated by warm or cold 
applications and massage carefully administered. 

As a sedative morphin may be administered, and 
weakening perspirations may be counteracted by 
aspirin. Calcium may be administered to advantage, 
either as calcium lactate in doses of 4 grains three 
times a day, or calcium glycerophosphate in powder or 
capsule, 5 grains three times a day. 

Chronic Myocarditis 

This is the term applied to a condition which is 
actually not an inflammation but a long continued 
degeneration. It is often a part of an arteriosclerosis. 
This being the case, the causes are any of the con- 
ditions which are associated with the appearance of 
arteriosclerosis : old age ; syphilis ; gout ; repeated 
attacks of rheumatism; excesses, especially in food 
and alcohol; prolonged wasting diseases such as 
tuberculosis or cancer. The myocardial changes are 
sometimes associated with chronic pericarditis and 
chronic endocarditis, and may accompany or follow 
valvular disease of the heart. 

The symptoms of chronic myocardial degeneration 
are progressive weakness, slight at first, noticeable on 
exertion; the pulse frequently becomes more rapid. 
There is likely to be edema of the lower extremities 
toward night. The amount of urine may diminish. 
The pulse may become intermittent, and then irregular. 

The physical signs often show an enlargement of 
the heart. Such a heart may act perfectly until a 
sudden exertion causes it to weaken, giving cardiac 
distress signals, the patient becoming prostrated for 
a variable period. Slight cardiac pains and sensations 
referred to the cardiac region become frequent. 

TREATMENT OF CHRONIC MYOCARDITIS 

Patients with this disturbance should avoid physical 
effort and mental weariness ; should avoid the swamp- 
ing of the circulation with fluids ; should reduce the 
quantities of food taken; should cause daily free 
movements of the bowels; should take warm baths 
daily to clean the skin and promote perspiration; 
should take a correct amount of cautious exercise or 



L 



322 DRUGS IN MYOCARDITIS 

undergo carefully directed calisthenics or massage. 
The patient should avoid chilling the body or placing 
any other sudden strain on the weakened heart mus- 
culature. Complete rest one day a week and one 
month in the year may aid in prolonging life. 

It is inadvisable to give nitrites if the blood pressure 
is low. If there is a high blood pressure nitroglycerin 
or other nitrites may be given. 

When an iodid is deemed advisable, the potassium 
or the sodium salt may be used, and either may be 
given in a saturated solution or in a solution of which 
a dose would be a teaspoonful. 

There is no syrup or tasteful menstruum that will 
well disguise the taste of an iodid. It is much better 
to give these preparations in water and allow the 
patient to take them either in milk or effervescing 
water, or in any solution that he may prepare to suit 
his taste, or he may follow the drug with any taster 
that he desires. 

Gm. or c.c. 

B Sodii iodidi 20| or 3v 

Aquae q. s. ad saturandum q. s. ad sat. 

M. et Sig. : Five drops, in water, three times a day, after 
meals. 

[Each minim represents about .065 gram or 1 grain of the 
drug. A drop, however, of a saturated solution is less than 
a minim.] 

Or: 

Gm. or c.c. 

fy Potassii iodidi 6| or 3 iss 

Aquae 100| AS iii 

M. et Sig. : A teaspoonful, in water, three times a day, 
after meals. 

If, in spite of this management and treatment, the 
patient has cardiac asthma attacks, with or without 
pain, especially if there are pendent edemas, the ques- 
tion arises as to whether or not digitalis should be 
given. In such cases one cannot tell without trying 
whether digitalis will be of benefit or will cause more 
discomfort. A small dose of an active preparation 
should be given at first twice in twenty-four hours, 
and after a week once in twenty-four hours, its action 
being carefully watched and the decision as to whether 
the dose is too large or too small arrived at. 



ENDOCARDITIS 

Acute endocarditis rarely if ever occurs without 
some myocarditis, and not infrequently pericarditis 
also accompanies these conditions. Endocarditis is 
divided for discussion into acute mild (simple) endo- 
carditis; acute malignant (ulcerative) endocarditis: 
chronic endocarditis and valvular disease. 

Acute Mild Endocarditis 

It has been shown positively that acute endocarditis 
is due to micro-organisms, generally streptococci, 
staphylococci or pneumococci, and, more frequently 
than once believed, gonococci. The most frequent 
causes are acute rheumatic fever, diphtheria, pneu- 
monia, cerebrospinal meningitis, scarlet fever, ery- 
sipelas, influenza, chorea, gonorrhea, sepsis and typhoid 
fever. It may also follow a follicular tonsillitis which 
is rheumatic in type but has not caused arthritis. 
Tuberculosis may also occasionally cause an endo- 
carditis. Organisms may be found in a terminal simple 
endocarditis due to a chronic disease, as tuberculosis 
or cancer ; such inflammations may have been caused 
by circulating toxins. 

This inflammation of the endocardium is generally 
confined to the region of the valves, and the valves 
most frequently so inflamed are the mitral and aortic. 
There may be a slight inflammation or actual ulcera- 
tion and loss of tissue. Vegetations more or less 
constantly occur on the inflamed surfaces, with more 
or less danger of particles becoming loosened and 
moving free in the blood-stream, causing embolic 
obstruction in different parts of the body. There is 
also more or less probability of serious adhesions or 
contractions occurring from the healing of the ulcer- 
ated surfaces. In other words, the future health and 
welfare of the valves depends on the fact that the 
inflammation has healed without contractions or 
adhesions. 

It is often difficult to decide when acute endo- 
carditis has developed, but with the knowledge that 
the endocardium often becomes inflamed during almost 
any of the acute infections, the physician should 
repeatedly examine the heart for murmurs, for muffled 



324 TREATMENT OF ENDOCARDITIS 

closure of the valves, or for other evidences of endo- 
carditis or myocarditis during the acute infective 
process. 

SYMPTOMS 

Among the early symptoms of endocarditis, which 
is often not recognized until the appearance of a 
valvular lesion, may be pain or discomfort about the 
heart and a rise in temperature. Frequently also there 
may be some dyspnea. Patients so afflicted are usually 
nervous and restless, and inclined to show anxiety on 
strenuous movement. 

TREATMENT 

In the treatment of acute mild endocarditis, rest, 
both mental and physical, is of primary importance. 
This should extend over four to six weeks and should 
be absolute. To counteract muscular flabbiness, mas- 
sage should be given, extending from simple rubbing 
and kneading to passive movements. 

Locally the application of cold is most useful. Ice 
bags should not be applied directly to the skin, but the 
latter should be covered with a light piece of flannel. 
A blister usually causes more discomfort than it does 
good. 

The medicinal treatment includes the use of alkalies. 
These may be given as potassium citrate in doses of 
2 gm. every three to six hours in wintergreen water. 
If the salicylates are being given, as they should be, 
to counteract rheumatic infection, sodium bicarbonate 
may be given in equal dosage. To counteract the 
anemia likely to develop, iron may be administered 
as 5 drops of the tincture of the chlorid in lemonade 
or orangeade, twice in twenty-four hours. A 3 grain 
tablet of saccharated oxid of iron may be given twice 
in twenty-four hours. Pain may be combated by the 
use of morphin in adults or codein if the patient be a 
child. 

For marked nervousness and restlessness, the 
bromids may be of value and in case of insomnia, 
chloral or sodium-ethyl-barbiturate may be used, a 
dosage of 3 to 5 grains being ordinarily sufficient. 

Diet.— The diet should at first consist largely of 
milk and cereals with a moderate amount of fluid and 



ULCERATIVE ENDOCARDITIS 325 

alkaline drinks. During convalescence a full diet may 
be prescribed, especially milk, eggs and fresh vege- 
tables. The bowels should be kept open but a too 
brisk catharsis is inadvisable. It is better to regu- 
late the bowels by simple measures such as proper 
foods, etc. 

The correct use of cardiac drugs is a difficult prob- 
lem. If there is myocardiac inflammation digitalis 
is inadvisable as is the case in the presence of much 
endocardial inflammation. If there are signs of failure 
of the cardiac muscle, camphor or strophanthin have 
been advised when rapid stimulation is needed. 

For hyperpyrexia and profuse perspiration, the 
surface of the body should be sponged with cold, 
lukewarm or warm water. Too profuse sweating 
may be combated with atropin. 

Malignant (Ulcerative) Endocarditis 

Ulcerative endocarditis may develop from the mild 
type or independently of it. It is essentially a septic 
process and may develop from a local focus of infec- 
tion elsewhere in the body. The process may include 
disintegration of the heart muscle and deep points 
of erosion as well as little pockets of pus or abscesses 
in the muscle tissue. 

The diagnosis is not so difficult if this condition 
develops on a mild endocarditis as when it appears 
primarily. The temperature is generally intermittent, 
accompanied by chills. There may be prostration and 
profuse sweats, 

Meningeal symptoms — headache, restlessness, deli- 
rium, stupor — are not uncommon and convulsions may 
occur. Enlargement of the spleen and congestion of 
the liver may be found. Albumin appears in the 
urine. Definite cardiac symptoms and cardiac weak- 
ness eventually dominate the picture. Ecchymotic 
spots may appear over the body. If emboli break off 
and are carried to different parts of the body they 
bring about symptoms of embolism in that part. If 
mycotic, they may set up a local focus of infection ; 
if lodging in a terminal artery gangrene of the part 
concerned takes place, necessitating amputation, or 
perhaps being itself the cause of death. 



326 TREATMENT OF MALIGNANT ENDOCARDITIS 
TREATMENT OF MALIGNANT ENDOCARDITIS 

If pneumonia or gonorrhea is supposed to be the 
cause of the endocarditis, injections of stock vaccines 
should perhaps be used. If the form of sepsis was 
not determinable, streptococci or staphylococci vaccines 
might be administered. It is still a question whether 
such "gun-shot" medication with bacteria is advisable. 
Patients recover at times from almost anything, and 
the interpretation of the success of such injection 
treatment is difficult. Exactly how much harm such 
injections of unnecessary vaccines can produce in a 
patient is a question that has not been definitely 
decided. Theoretically an autogenous vaccine is the 
only vaccine that should be supposed to be successful 
with our present knowledge. The vaccine treatment 
of ulcerative endocarditis was not shown to be very 
successful by Dr. Frank Billings in his investigation 
of the subject. 

Other treatment of malignant endocarditis includes 
treatment of the condition that caused it plus treat- 
ment of "mild" endocarditis, as previously described, 
with the meeting of all other indications as they occur. 
xAs in septic processes, the nutrition must be pushed to 
the full extent to which it can be tolerated by the 
patient, namely, small amounts of a nutritious, varied 
diet given at three-hour intervals. 

Whether milk or any other substance containing lime 
makes fibrin deposits on the ulcerative surfaces more 
likely or more profuse, and therefore emboli more 
likely to occur, is perhaps an undeterminable question. 
In instances in which hemorrhages so frequently occur, 
as they do in this form of endocarditis, calcium is 
theoretically of benefit. Quinin has not been shown to 
be of value, nor has salicylic acid, unless the cause is 
rheumatism. Alcohol has been used in large doses, as 
it has been so frequently used in all septic processes. 
If the patient is unable to take nourishment in any 
amount, small doses of alcohol may be of benefit. It 
is probably of no other value. It is doubtful whether 
ammonium carbonate tends to prevent fibrin deposits 
or clots in the heart, as so long supposed. In fact, 
whenever the nutrition is low and the patient is likely 
to have cerebral irritation from acidemia, whenever the 



CHRONIC ENDOCARDITIS 327 

kidneys are affected, or whenever a disease may tend 
to cause irritation of the brain and convulsions, it is 
doubtful if ammonium carbonate or aromatic spirit of 
ammonia is ever indicated. Ammonium compounds 
have been shown to be a cause of cerebral irritation. 

Intestinal antisepsis may be attained more or less 
successfully by the administration of yeast or of lactic 
acid ferments together with suitable diet. The nuclein 
of yeast may be of some value in promoting a leukocy- 
tosis. It has not been shown, however, that the poly- 
morphonuclear leukocyte increase caused by nuclein 
has made phagocytosis more active. 

Malignant endocarditis may prove fatal in a few 
days, or may continue in a slow subacute process for 
weeks or even months. 

Chronic Endocarditis 

It is not easy to determine when a subacute endo- 
carditis becomes chronic. The process manifests itself 
by a gradual sclerosis of the valves. It should be 
treated on the same principles as the acute type 
depending largely on the supposed cause of the disease. 

CHRONIC VALVULAR DISEASE 

As has been indicated, chronic valvular disease 
arises commonly as the result of acute or chronic endo- 
carditis, the former from infections, the latter per- 
haps associated with syphilis, alcoholism, gout, etc. 

The valvular disease may narrow or constrict the 
opening, giving rise to so-called stenosis ; or it may 
render the valves incapable of closing correctly, 
so-called insufficiency. Because of its increased work 
the heart muscle may hypertrophy. As long as this 
hypertrophy is adequate the heart continues its work 
satisfactorily and the valvular lesion is said to be 
compensated. When the muscle is degenerated it may 
be unable to accomplish its work and is said to fail, 
and symptoms of cardiac failure appear. As the 
heart chambers overfill and are emptied with difficulty, 
dilation takes place. 



L 



328 MITRAL STENOSIS 

THE COMPENSATED HEART 

As long as compensation is complete no medication 
or physical treatment is necessary. However, such a 
patient should so order his life as to throw no special 
strain on the taxed organ. Severe athletic efforts, 
rushing up and down stairs, prolonged tension, 
extreme worry are to be interdicted. Tobacco and 
alcohol, tea and coffee should not be taken. Ordinary 
diseases occurring in such patients should be treated 
with exceptional watchfulness of the circulation. 

MITRAL STENOSIS 

Perhaps 60 per cent, of mitral stenosis, which occurs 
most commonly between the ages of ten and thirty, 
has its origin in rheumatic endocarditis. This lesion 
is a serious handicap in such diseases as pneumonia, 
pleurisy or bronchitis, in which there is congestion of 
the lungs. 

Among the more important symptoms are a mur- 
mur, diastolic and perhaps presystolic, heard over the 
left ventricle and accentuated at the apex. Usually 
there is an accentuated pulmonary closure. The pulse 
is generally slow ; dyspnea on exertion is common and 
an increase in mucus in the throat is not infrequent. 

As weakening of the compensation occurs, the heart 
beat becomes irregular; there is venous congestion of 
the head and face, blueing of the lips and sometimes 
hemoptysis. These patients suffer more or less from 
cold extremities. 

Besides the usual treatment for broken compensa- 
tion in patients with this lesion, digitalis is of the 
greatest value, and the slowing of the heart by it, 
allowing the left ventricle to be more completely filled 
with the blood coming through the narrowed mitral 
opening during the diastole, is the object desired. 
This drug acts similarly on both the right and left 
ventricles, and though there is no real occasion for 
stimulation of the left ventricle, and it is the right 
ventricle that is in trouble, dilated and failing, still a 
greater force of left ventricle contraction helps the 
peripheral circulation. The action on the right ventricle 
contributes greatly to the relief of the patient by send- 
ing the blood through the lungs and into the left 



MITRAL REGURGITATION 329 

auricle more forcibly, and the left ventricle receives 
an increased amount of blood, the congestion in the 
lungs is relieved and the dyspnea improves. Perhaps 
there is no class of cardiac diseases in which more 
frequent striking relief can be obtained than in these 
cases of mitral stenosis. 

If the congestion of the lungs is very great and 
death seems imminent from cardiac paralysis, if 
cyanosis is serious and bloody, frothy mucus is being 
expectorated, venesection and an intramuscular injec- 
tion of aseptic ergot may be indicated. Digitalis should 
also be given, hypodermatically perhaps, but its action 
would be too late if it was not aided by other more 
quickly acting drugs, such as strophanthus. The 
physician may often save life by such radical measures. 

MITRAL INSUFFICIENCY 2 MITRAL REGURGITATION 

This is the most frequent form of valvular disease 
of the heart, and is due to a shortening or thickening 
of the valves, or to some adhesion which does not 
permit the valves to close properly, and the blood 
consequently regurgitates from the left ventricle info 
the left auricle during the contraction of the ventricle. 
Such regurgitation may occur without valvular disease 
if for any reason the left ventricle becomes dilated 
sufficiently to cause the valve to be insufficient. Such 
a dilatation can generally be cured by rest and treat- 
ment. As with mitral stenosis, the most frequent 
causes are rheumatism and chorea, with the occasional 
other causes as previously enumerated. 

The characteristic murmur of this lesion is a systolic 
blow, accentuated at the apex, transmitted to the left 
of the thorax, generally heard in the back, near the 
lower end of the scapula, and transmitted upward 
over the precordia. 

Of all cardiac lesions, this is the safest one to have. 
Sudden death is unusual, the compensation of the 
heart seems to be most readily maintained, and the 
patient is not so greatly dangered by overexertion or 
by inflammations in the lungs. As in mitral stenosis, 
any increase in blood-pressure — whether the normal 
increase after the age of 40, any continued earlier 
high tension or increase from occupation or exercise — 



330 AORTIC STENOSIS 

is serious as causing the left ventricle to act more 
strenuously, so that more blood is forced back into 
the left auricle, the lungs become congested, and the 
right ventricle, sooner or later, becomes incompetent. 

When compensation fails with these patients, the 
first sign is pendent edema of the feet, ankles and 
legs ; subsequently, if there is progressive failure of 
compensation, the usual symptoms occur. 

The treatment is principally rest and digitalis, and 
the recovery of compensation is often almost phe- 
nomenal. Patients with this lesion are likely to be 
children and young adults, and the heart muscle 
readily responds as a rule to the treatment inaugurated. 
Later, in these patients, or if the lesion occurs in older 
patients, the return to compensation does not occur 
so readily. If the condition is developed from a 
myocarditis or from fatty degeneration of the heart, 
it may be impossible to cause the left ventricle to 
improve so much as to overcome this relative dilata- 
tion or relative insufficiency of the valve. If the 
dilatation of the left ventricle is due to some poisoning 
such as nicotin, with proper treatment — stopping the 
use of tobacco, administration of digitalis, and rest — 
the heart muscle will generally recover and the valve 
again properly close. 

AORTIC STENOSIS ! AORTIC OBSTRUCTION 

Valvular disease at the aortic orifice is much less 
common than at the mitral orifice, and while stenosis 
or obstruction is less common from rheumatism or 
acute inflammatory endocarditis than is insufficiency 
of this valve, a narrowing or at least the clinical sign 
of narrowing, denoted by a systolic blow at the base 
of the heart over the aortic opening, is in arterio- 
sclerosis and old age of frequent occurrence. If such 
narrowing occurs without aortic insufficiency at the 
age at which it usually occurs, it may not seriously 
affect the heart. It may follow acute endocarditis, 
but it most frequently follows chronic endocarditis 
or atheroma, in which the aortic valves become 
thickened and more or less rigid ; this condition most 
frequently occurs in men. 

Anything that tends to increase arterial tension, as 
tobacco, lead or hard work, or anything that tends to 



AORTIC STEXOSIS 331 

cause arterial disease, as alcohol or syphilis, is often 
the cause of this lesion. 

At times the edges of the valves may grow together 
from ulcerative inflammation, and the lumen thus be 
diminished in size ; or projecting vegetations may inter- 
fere with the opening of the valve and with the flow 
of blood. With such narrowing the left ventricle 
more or less rapidly hypertrophies to overcome its 
increased work. 

The murmur caused by this lesion is a systolic one, 
either accentuated in the second intercostal space at 
the right of the sternum, or perhaps heard loudest 
just to the left of the sternum in this region. The 
murmur is also transmitted up the arteries into the 
neck, and may at times be heard in the subclavian 
arteries. It may also be transmitted downward over 
the heart. The pulse is slow, the apex of the rise of 
the sphygmographic arterial tracing is more or less 
sustained and rounded, and the rise is much less than 
normal. 

If this lesion occurs in old age, there is general 
arterial disease present and the tension and compress- 
ibility of the arteries vary, depending on how much 
they are hardened. The disturbed circulation is evi- 
denced by imperfect peripheral circulation and capil- 
lary sluggishness, with at times pendent edema of 
the feet and ankles, but, perhaps, little congestion of 
the lungs. The left ventricle being sufficient, there 
is no damming back through the left auricle to the 
lungs. The left ventricle may, however, become 
weakened, either by some sudden strain or by a chronic 
myocarditis, and relative insufficiency of the mitral 
valve may occur. The subsequent symptoms are 
typically those of loss of compensation. 

This lesion may allow a patient to live for years, 
provided no other serious disturbance of the heart 
occurs, such as myocarditis or coronary disease ; but 
sooner or later, with the failing force of the blood- 
flow and the lessened aortic pressure, slight attacks 
of anemia of the brain occur, causing syncope or 
fainting. Also, sooner or later these patients have 
little cardiac pains. They begin to ''sense" their hearts. 
Their may not be actual anginas, but a little feeling 



332 AORTIC STENOSIS 

of discomfort, with perhaps pains shooting up into 
the neck, or a feeling of pressure under the sternum. 
Little excitements or over-exertions are likely to make 
the heart attempt to contract more rapidly than it is 
able to drive the blood through the narrowed orifice, 
and this alone causes cardiac discomfort and the feel- 
ing of cardiac oppression. 

It is essential, then, that these patients should not 
hasten and should not become excited ; and any drug 
or stimulant that would cause cardiac excitement is 
bad for them. On the other hand, these are the very 
patients in whom, sometimes, alcohol in small doses 
may be advisable, especially if the patient is old ; and 
a dose of alcohol used medicinally when an attack of 
cardiac disturbance is present is good treatment. The 
quick dilatation is valuable. Nitroglycerin will also 
do good work in these cases, and with high blood- 
tension may be the only safe drug for the patient to 
have on hand. As soon as his attack occurs, with or 
without real angina pectoris, let him dissolve in his 
mouth a nitroglycerin tablet. If he feels faint, he will 
feel better the moment he lies down, and in this 
instance he may be improved by a cup of coffee, or 
a dose of caffein, camphor or ammonia. 

If the left ventricle becomes still weaker and shows 
signs of serious weakness, or if there is actual dilata- 
tion, the question of whether or not digitalis should 
be used is a subject for careful decision. The left 
ventricle should not be forced to act too sturdily 
against this aortic resistance. Consequently the dose 
of digitalis must be small. On the other hand, it 
frequently happens, especially in old age, that myo- 
carditis or fatty degeneration has already occurred 
before this cardiac weakness develops in the presence 
of aortic narrowing, and digitalis may not be indicated 
at all. We cannot tell how far degeneration may have 
gone, however, and small doses of digitalis used ten- 
tatively and carefully, perhaps two or three drops 
of an active tincture two or three times a day, and 
then the drug carefully increased to a little larger 
dose to see whether improvement takes place, is the 
only way to ascertain whether digitalis can be used 
with advantage or not. If it increases the cardiac 






AORTIC REGURGITATION 333 

pain and distress, it should not be used. Strychnin 
is then the drug that should be relied on, with such 
other general medication as is needed, combined with 
the coincident administration of nitroglycerin, which 
may also be given in conjunction with digitalis, if 
deemed advisable. Generally, however, if a heart with 
aortic stenosis needs stimulation the blood-pressure is 
generally none too high, although there may be arterio- 
sclerosis present. Therefore when nitroglycerin is 
indicated to lower blood-pressure, digitalis is not 
usually indicated; when digitalis is indicated to aid 
the heart, nitroglycerin is generally not indicated. 
These patients must have high blood-pressure to sus- 
tain perfect circulation at the base of the brain. 

Patients who have this lesion should not use tobacco 
in large amounts, or sometimes even small amounts, 
as tobacco raises the blood-pressure and thus puts 
more work on the left ventricle; in the second place, 
if the left ventricle is failing, much tobacco may hasten 
its debility. On the other hand, with a failing left 
ventricle and a long previous use of tobacco it is no 
time to prohibit its use absolutely. A failing heart 
and the sudden stoppage of tobacco may prove a 
serious combination. 

aortic insufficiency: aortic regurgitation 

This lesion, though not so common as the mitral 
lesion, is of not infrequent occurrence in children and 
young adults as a sequence of acute rheumatic endo- 
carditis. If it occurs later in life it generally is asso- 
ciated with aortic narrowing, and is a part of the 
general endarteritis and perhaps atheroma of the 
aorta. Sometimes it is caused by strenuous exertion 
apparently rupturing the valve. 

This form of valvular disease frequently ends in 
sudden death. On the other hand, it is astonishing 
how active a person may be with this really terrible 
cardiac defect. This lesion, from the frequent over- 
distension of the left ventricle, is one that often causes 
pain. While the left ventricle enlarges enormously 
to overcome the extra distention due to the blood 
entering the ventricle from both directions, the muscle 
sooner or later becomes degenerated from poor coro- 



334 TRICUSPID INSUFFICIENCY 

nary circulation. Unless the left ventricle can do its 
work well enough to maintain an adequate pressure 
of blood in the aorta, the coronary circulation is insuf- 
ficient, and chronic myocarditis is the result. If the 
left ventricle has maintained this pressure for a long 
time, edemas are not common unless the cardiac weak- 
ness is serious and generally permanently serious ; that 
is, slight weakness, in this lesion, does not give edemas 
as does slight loss of compensation in mitral disease, 
and unless the weakness of the ventricle is serious, 
the lungs are not much affected. 

The physical sign of this lesion is the diastolic mur- 
mur, which is loudest at the base of the heart, is 
accentuated over the aortic orifice, arid is transmitted 
up into the neck and the subclavians, and down over 
the heart and down the sternum with marked pulsa- 
tions of the arteries (Corrigan pulse) and often of 
some of the peripheral veins, notably of the arms and 
throat. 

If the left ventricle becomes dilated the mitral valve 
may become insufficient, when the usual lung symp- 
toms occur, with hypertrophy of the right ventricle ; 
and if it fails, the usual venous symptoms of loss of 
compensation follow. This lesion not infrequently 
causes epistaxis, hemoptysis and hematemesis. 

Digitalis is always of value in these cases, but it 
should not be pushed. If a heart is slowed too much 
the regurgitation into the left ventricle is increased. 
Therefore such hearts should not be slowed to less 
than eighty beats per minute, or sudden anemia of the 
brain and sudden death may occur. These patients 
must not do hard work. 

TRICUSPID INSUFFICIENCY 

This rarely, if ever, occurs alone ; it is generally 
a sequence of other valvular defects, and represents 
an overworked, dilated right ventricle. It mav, how- 
ever, occur from lesions of the lungs which impede 
the blood-flow through them. Such are fibroid 
changes in the lungs, emphysema, prolonged chronic 
bronchitis, the last stages of pulmonary tuberculosis, 
old neglected pleurisies with cirrhosis or fibrosis of 
the lung, and repeated attacks of asthma — anything. 



PULMOXARY IXSUFFICIEXCY 335 

whether valvular defect or pulmonary circulatory dis- 
turbance, that increases the pressure ahead and the 
work of this ventricle. 

The symptoms are those of loss of compensation 
as described under other valvular lesions. There may 
be jugular pulsation, especially evident in the external 
jugular on the left side. The liver enlarges and may 
pulsate. There are edemas, dropsies, ascites and per- 
haps hemorrhages. The heart is enlarged and there 
is a soft systolic blow heard at the lower end of the 
sternum. The dyspnea is sometimes very great, and 
cyanosis may be present, especially during paroxysms 
of coughing. 

This lesion of the heart is always benefited by 
digitalis, but the continuance of the improvement and 
its amount depend, of course, on the cause of the dila- 
tation of the ventricle. Strychnin is often of advan- 
tage. These patients should rarely receive vasodilators, 
and hot baths, overheating, overloading the stomach 
and vigorous purging should never be allowed. Some- 
times improvement will not take place until ascitic 
or pleuritic fluid, if present, has been removed. 

TRICUSPID STENOSIS I TRICUSPID OBSTRUCTION 

This is rare and probably always congenital, and is 
supposed to be due to an inflammation of the endo- 
cardium during intra-uterine life. In early childhood 
it is possible that it may be associated with left-side 
endocarditis. 

A special treatment of the heart, if any is needed, 
would probably not be indicated unless there was 
associated tricuspid insufficiency, when digitalis might 
be used. 

PULMONARY INSUFFICIENCY I PULMONARY 
REGURGITATION 

If this rare condition occurs, it is probably congeni- 
tal. A distinctive murmur of this insufficiency would 
be diastolic and accentuated in the second intercostal 
space, on the left of the sternum. It should be remem- 
bered that aortic murmurs are often more plainly 
heard at the left of the sternum. Sooner or later, if 



336 ACUTE HEART ATTACK 

this lesion is actually present, the right ventricle dilates 
and cyanosis and dyspnea occur. Digitalis would there- 
fore be indicated. 

PULMONARY STENOSIS ! PULMONARY OBSTRUCTION 

If stenosis is actually present in this location, the 
lesion is probably congenital. It might occur after a 
serious acute infectious endocarditis, but then it would 
be associated with other lesions of the heart. It has 
been found to be associated with such congenital 
lesions of the heart as an open foramen ovale or fora- 
men Botalli, or with an imperfect ventricular septum, 
and perhaps with tricuspid stenosis — in short, a cardiac 
congenital defect. The right ventricle becomes hyper- 
trophied, if the child lives to overcome the obstruction. 

The physical sign is a systolic blow at the second 
intercostal space on the left; but as just stated, such a 
murmur must surely be dissociated from an aortic 
murmur if found to develop after babyhood, and it 
should also be diagnosed from the frequently occurring 
hemic, basic and systolic murmurs ; that is, if signs of 
pulmonary lesions are not heard soon after birth or in 
early babyhood, the diagnosis of pulmonary defects can 
be made only by exclusion. 

Unless the right ventricle is found later to be in 
trouble, there is no treatment for this condition. If 
the right ventricle dilates, digitalis may be of benefit. 

ACUTE HEART ATTACK 

The patient with valvular disease may suddenly be 
seized with an acute attack of agony in the heart 
region, dyspnea, and a feeling of oppression. A 
patient in this condition may die at any moment. 

The immediate conditions to be met are the rapid 
fluttering heart, the nervous excitation and the vaso- 
motor spasm, as well as the cardiac anxiety. Two fac- 
tors of great importance are the establishment of self- 
control and confidence by the patient and the spon- 
taneous relaxation following exhaustion. Morphin 
may be giVea even when there is no pain to aid in 
this relaxation. A too large dose should not be 
given because of the consequent depressing effect on 
the respiratory center. Atrophifl may be given with 



BROKEN COMPENSATION 337 

the morphin to overcome this effect. Such drugs 
should be given hypodermically as the patient is likely 
to vomit any mixture given by mouth. Nitroglycerin 
may be given hypodermically in dosage of 1/100 or 
1/200 grain or a tablet may be dissolved on the tongue 
to aid in relaxing the peripheral vessels. 

If the patient collapses with marked dyspnea, sub- 
normal blood pressure, cyanosis, feeble pulse, etc., and 
does not have the tension of fear, the treatment should 
be somewhat different. Aseptic ergot may be injected 
at once intramuscularly. If the patient has not been 
overpowered with digitalis it may be advisable to 
administer some form of this drug to obtain the future 
continued action. 

Strophanthin may be given intravenously and in this 
way is a quickly acting stimulant. The dosage should 
be from 1/500 to 1/200 grain. Atropin or strychnin 
may be used also to stimulate the flagging circulation in 
this condition. A saturated solution of camphor in 
sterile oil given hypodermically is a quickly acting 
stimulant. In this type of heart attack alcohol is con- 
traindicated absolutely. 

BROKEN COMPENSATION 

Rest in bed, in a bedroom that is attractive, with 
fresh air and sunlight is of great importance. In 
patients over 50 it may be a question as to whether 
some exercise should not be advised. The patient 
should be individualized and proper measures taken to 
give mental and physical rest, to prevent excitement, 
worry and melancholia. 

DIET 

The diet should be adequate but not profuse nor defi- 
cient. Large quantities of fluids cause discomfort. 
The diet should be sufficiently varied to encourage 
appetite. In case there is dropsy or any accumulation 
of fluid, the intake of fluids may be greatly restricted 
and only a moderate quantity of salt should be 
included in the diet. 

ELIMINATION 

The elimination of the patient should be encouraged 
but should not be drastic. Hot sponge baths and warm 



338 TREATMENT OF BROKEN COMPENSATION 

alcohol rubs may be given and accompanied by gentle 
massage. Diuretics generally act unsatisfactorily in 
cardiac conditions. If the secretion of urine suddenly 
becomes small, the diet should be quickly reduced and 
the elimination through the skin watchfully encour- 
aged. The bowels should move satisfactorily daily. 
Active watery purgings are rarely advisable and simple 
vegetable laxatives are usually sufficient. 

MEDICAL TREATMENT WITH CARDIAC STIMULANTS 

Digitalis or some of its preparations is the drug 
of chief reliance in this condition, dependent, of course, 
on the amount of good heart muscle available for 
it to act on. It is advisable to use a tincture of known 
character beginning with a moderate dose, perhaps 
5 minims in eight hours and increasing a few days 
later to ten drops once in twelve hours and later to 
fifteen or twenty drops once a day. The action is 
cumulative and the drug should not be continued 
longer than five or six days without intermission. 
Strophanthus may be used as an alternating drug. A 
number of special preparations of digitalis are 
described in New and Nonofficial Remedies. Digitalis 
or its preparations should not be used when there is 
a fatty degeneration of the heart ; it should ordinarily 
not be used if there is arteriosclerosis or coronary 
disease. The signs of overaction of digitalis are 
nausea, vomiting, a diminished amount of urine, 
occipital headache or coldness of the hands and feet. 
The pulse may be reduced to sixty or less a minute. 

In such instances the drug should be stopped imme- 
diately, saline laxatives may be given and hot sponge 
baths, and perhaps alcohol or nitroglycerin. 

Strophanthus is a drug of little value in restoring 
compensation but it acts quickly and its power of 
stimulating the heart and contracting the blood vessels 
lasts a long time. 

Caffein, given as coffee or citrated caffein, V/2 
grains two or three times early in the day acts as a 
stimulotonic to the heart, increasing its activity. It 
is contraindicated in the presence of good compensa- 
tion. Jl is a cerebral stimulant. Strychnin promotes 
all muscular activity and is a general nervous stimu- 



CONVALESCENCE 339 

lant. It may be indicated when the heart is acting 
sluggishly and digitalis is not accomplishing what it 
was intended for. 

Other drugs are to be used as indicated in various 
complications which may be met. 

CONVALESCENCE 

When compensation has been restored, the patient 
may be allowed gradually to resume his usual habits 
and work, provided that these habits are sensible, and 
that the work is not one requiring severe muscular 
exertion. Careful rules and regulations must be laid 
down for him, depending on his age and the condition 
of his arteries, kidneys and heart muscle. It should 
be remembered that a patient over 40, who has had 
broken compensation, is always in more danger of a 
recurrence of this weakness than one who is younger, 
as after 40 the blood-pressure normally increases in 
all persons, and this normal increase may be just too 
much for a compensating heart which is overcoming 
all of the handicap that it can withstand. Such 
patients, then, should be more carefully restricted in 
their habits of life, and also should have longer and 
more frequent periods of rest. 

The avoidance of all sudden exertion in any instance 
in which compensation has just been restored is too 
important not to be frequently repeated. The child 
must be prevented from hard playing, even running 
with other children, to say nothing of bicycle riding, 
tennis playing, baseball, football, rowing, etc. The 
older boy and girl may need to be restricted in their 
athletic pleasures, and dancing should often be pro- 
hibited. Young adults may generally, little by little, 
assume most of their ordinary habits of life ; but 
carrying heavy weights up-stairs, going up more than 
one flight of stairs rapidly, hastening or running on 
the street for any purpose, and exertion, especially 
after eating a large meal, must all be prohibited. 
Graded physical exercise or athletic work, however, is 
essential for the patients' future health, the first walk- 
ing and later more energetic exercise may be advisable. 

These patients must not become chilled, as they are 
likely to catch cold, and a cold with them must not 



340 CONVALESCENCE 

be neglected, as coughing or lung congestions are 
always more serious in valvular disease. Their feet 
and hands, which are often cold, should be properly 
clothed to keep them warm. Chilling of the extremities 
drives the blood to the interior of the body, increases 
congestion there, and by peripheral contraction raises 
the general blood-pressure. A weak heart generally 
needs the blood-pressure strengthened, but a compen- 
sating heart rarely needs an increase in peripheral 
blood-pressure, and any great increase from ftuy 
reason is a disadvantage to such a heart. The patient 
should sleep in a well-ventilated room, but should not 
suffer the severe exposures that are advocated for 
pulmonary tuberculosis, as severe chilling of the body 
must absolutely be avoided. 

The peripheral circulation is improved, the skin is 
kept healthy, the general circulation is equalized, and 
the heart is relieved by a proper frequency of warm 
baths. Cold baths are generally inadvisable, whether 
the plunge, shower or sponging; very hot baths are 
inadvisable on account of causing a great deal of 
f aintness ; while warm baths are not stimulating and 
are sedative. The Turkish and Russian bath should 
be prohibited. They are never advisable in cardiac 
disease. With kidney insufficiency, body hot-air treat- 
ment (body-baking), carefully supervised, may greatly 
benefit a patient who has no dilatation of the heart and 
who has no serious broken compensation. Surf-bath- 
ing and, generally, sea-bathing and lake-bathing are 
not advisable. The artificial sea-salt baths and carbon 
dioxid baths may do some good, but they do not lower 
the general blood-pressure so surely as has been advo- 
cated, and probably no great advantage is apt to be 
derived from such baths. If a patient cannot prop- 
erly exercise, massage should be given him intermit- 
tently. 

Any systemic need should be supplied. If the patient 
is anemic, he should receive iron. If he has no appe- 
tite, he should be encouraged by bitter tonics. If sleep 
does not come naturally, it must be induced by such 
means as do not injure the heart. 

Perhaps there is no better place in this series on 
diseases of the heart to discuss the diet in general and 






AXGIXA PECTORIS 341 

the resort treatment than at this point, as the question 
is one of moment after convalescence from a broken 
compensation, at which time every means must be 
inaugurated to establish a reserve heart strength to 
overcome the daily emergencies of life. 

ANGINA PECTORIS 

Angina pectoris is a name applied to the condition 
manifested by pain in the heart region due to the 
heart itself. 

The pain of true angina pectoris generally starts 
in the region of the heart, radiates up around the left 
chest, into the shoulder, and often down the left arm. 
Such a patient is likely to assume a characteristic 
posture. He stops still wherever he is, stands per- 
fectly erect or bends his body backward, raises his 
chin, supports himself with one hand and places the 
other over the heart. The duration of the attack is 
usually but a few seconds but the patient may die in 
the first or any subsequent attack. 

For treatment of the immediate pain, anything may 
be given that quickly relieves local or general arterial 
spasm and spasm of the muscles. The moment that 
the heart and its arterioles relax, the attack is often 
over. The most quickly acting drug for this purpose 
is amyl nitrite, inhaled. If amyl nitrite is not at hand, 
or has been found previously to cause considerable 
disturbance of the head or a feeling of prolonged 
faintness, nitroglycerin is the next most rapidly acting 
drug. It may be given hypodermatically, or a tablet 
may be dissolved on the tongue. The amyl nitrite 
should be in the emergency case of every physician 
in the form of ampules, or may be carried by the 
patient after he has had one or more attacks. The 
ampules now come made of very thin glass with an 
absorbent and silk covering ready for crushing with 
the fingers, and are thus immediately ready for inhala- 
tion. One of these is generally all that it is necessary 
to use at any one time. Nitroglycerin, if given hypo- 
dermatically, should be in dose of 1/100 grain. If 
given by mouth the dose should be the same, repeated 
in ten minutes if the pain has not stopped. 



342 ANGINA PECTORIS 

Almost coincidently with the administration of nitro- 
glycerin or the amyl nitrite a hypodermatic injection 
of 1/8 or 1/6 grain of morphin sulphate should be 
given without atropin, as full relaxation is desired 
without any stimulation of atropin. 

If a patient is home and at rest at the time of an 
attack, a hot-water bag but slightly filled, or a pad 
electrically heated may be placed over the heart some- 
times with marked advantage and relief from pain. 
Occasionally even such gentle applications are not 
tolerated. 

After the attack is over absolute rest for some 
hours, at least, is positively necessary. If the attack 
was severe, the patient should rest several days, as 
there seems to be a great tendency for such attacks 
to come in groups, the cause being acutely present 
for at least some time. But little food should be 
given ; nothing very hot or very cold, and no large 
amount of liquids ; gentle catharsis may be induced 
on the following day, if deemed advisable ; no stimu- 
lating drugs should be administered, and nothing that 
would raise the blood-pressure. 

The question often arises as to whether the patient 
shall be told of the seriousness of his condition. It is 
hardly wise to withhold this knowledge from him, 
and generally is not necessary. The ordinary alert 
patient knows how serious the condition is by his own 
feelings, and will even reprove or joke with his physi- 
cian for minimizing the danger. It is best that the 
whole subject be discussed carefully with him and his 
life regulated and ordered, and emergency drugs pre- 
pared and given him with proper instructions to the 
family, so that he may possibly prevent other attacks, 
and, if they occur, may have the best immediate 
treatment. 

The acute symptoms being over, a careful analysis 
of the probable cause of the anginal attack should be 
made. If it is a general sclerosis, the treatment should 
be directed to that condition. If it is a myocarditis, 
a fatty degeneration of the heart or a fatty heart, this 
should be properly treated as previously described. 
If it is due to a toxemia from intestinal disturbance, 
that may readily be remedied. If due to nicotin, it 



AURICULAR FIBRILLATION 343 

need not again occur from that reason, and perhaps 
the damage caused by the nicotin may be removed. 
Any organic kidney trouble must, of course, be man- 
aged according to its seriousness, and if there is hyper- 
tension without any serious lesion, the treatment 
should be directed toward its relief. 

AURICULAR FIBRILLATION 

While auricular fibrillation is a clinical entity, it 
is often difficult of diagnosis, and sometimes can be 
excluded only by treatment and the results of treat- 
ment, or by watching the patient for some time. When 
completely present, it consists really of a paralysis of 
the auricles ; normal systolic contractions of the 
auricles do not occur, although there are little jrapid 
twitchings of different muscle fibers of the auricles, 
which give the name to the condition. 

The irregular pulse in auricular fibrillation is more 
or less distinctive, being generally rapid, from 110 
upward. Occasionally the pulse-rate may be much 
slower, if the heart is under the influence of digitalis. 
The irregularity of the pulse in this condition is 
excessive ; the rate, strength and apparent intermit- 
tency during a half minute may not at all represent 
the condition in the next half minute, or. in the next 
several minutes. It has been thought that auricular 
fibrillation, while prevented many times by digitalis, 
is perhaps incurable. This is probably not true in 
the early stages of the condition. If digitalis does not 
cure the irregularity, the condition has been termed the 
"absolutely irregular heart." Other terms applied to 
the condition have been "ventricular rhythm," "nodal 
rhythm" and "rhythm of auricular paralysis." The 
condition of the pulse has been Latinized as pulsus 
irregularis perpetuus. 

While the condition is best diagnosed by tracings 
taken simultaneously of the heart, jugular and radial, 
still the jugular tracing is almost conclusive in the 
absence of the auricular systolic wave. The radial 
tracing is exceedingly suggestive, and if it is taken 
with a careful stethoscoping of the heart, an almost 
certain presumptive diagnosis may be made. 



344 AURICULAR FIBRILLATION 

OCCURRENCE 

This condition of auricular fibrillation occurs occa- 
sionally in valvular disease, and perhaps most fre- 
quently in mitral stenosis ; but it can occur without 
valvular lesions, and with any valvular lesion. If it 
occurs in younger patients, valvular disease is likely 
to be a cause; if in older patients, sclerosis or myo- 
cardial degeneration is generally present. 

It may also follow depressing infections such as 
diphtheria, or some infection that has caused a myo- 
carditis. Rarely this fibrillation may be caused by 
some of the drugs used to stimulate the heart. 

It is astonishing how few symptoms may be 
present with auricular fibrillation and an absolutely 
irregular heart action. The patient may be able to 
perform all of his duties, however strenuous, until 
coincident, concomitant or causative ventricular weak- 
ening and dilatation or broken compensation occurs, 
and then the symptoms are those due to the cardiac 
failure. Often in the first stage of this weakening 
and later fibrillation of the auricles the patient may 
recognize the cardiac irregularity and disturbances. 
Generally, however, he soon becomes accustomed to 
the sensations, and, unless he has cardiac pains or 
dyspnea, he becomes oblivious to the irregularity. At 
other times he may be conscious of irregular, strong 
throbs or pulsations of the heart, as such hearts often 
give an occasional extra sturdy ventricular contraction. 
These he notes. Real attacks of tachycardia may be 
superimposed on the condition. Sooner or later, how- 
ever, if the condition is not stopped, cardiac weakness 
and loss of compensation, with all the usual symptoms, 
occur. It seems to be probable that more than half 
of all cases of heart failure are due to auricular fibril- 
lation, or at least are aggravated by it. 

TREATMENT 

The condition may be stopped by relieving the heart 
and circulation of all possible toxins and irritants, and 
by the administration of digitalis. One attack is fre- 
quently followed by others, perhaps of longer dura- 
tion. Occasionally, however, the patient may be 
observed for many years without the condition again 



AURICULAR FIBRILLATION 345 

being present. If the pulse, in spite of treatment, is 
permanently irregular, and auricular insufficiency is 
permanent, the patient is of course in danger of cardiac 
failure; but still he may live for years and die of 
some other cause than heart failure. The prognosis 
seems to be better when the pulse is not rapid — below 
a hundred. This shows that the ventricles are not 
much excited and do not tend to wear themselves out. 

Any treatment that lowers the heart-rate is of advan- 
tage, such as the stopping of tea and coffee, the admin- 
istration of digitalis, and an increased amount of rest 
and quiet. Digitalis should be increased gradually 
until a fair dose is given, and it is better to administer 
one dose a day than several. If it causes undesired 
symptoms, such as cardiac pain, a tight feeling in the 
chest, nausea or vomiting, or a diminished amount of 
urine, it is not acting well and should be stopped. If 
the pulse is gradually slowed to about what is normal, 
its action should be considered successful. 

If the pulse is intermittent and there is apparently 
a heart-block, Stokes-Adams disease should be con- 
sidered as possibly present, and digitalis would be 
contraindicated and would do harm. 

A scientific indication as to whether a heart is dis- 
turbed through the action of the vagi nerves or whether 
the disturbance is due to muscle degeneration may be 
obtained by the administration of atropin. Talley 
(Amer. Jour Med. Sci., Oct., 1912) of Philadelphia 
shows the diagnostic, value of this drug. It is a familiar 
physiologic fact that stimulation- of the vagi slows the 
heart or even stops it. Stimulation of these nerves 
by the electric current, however, does not destroy the 
irritability of the heart; indeed, the heart may act by 
local stimulation after it has been stopped by pneumo- 
gastric stimulation. It is also a well-known fact that 
anything that inhibits or removes vagus control of the 
heart allows the heart to become more rapid since 
these nerves act as a governor to the heart's contrac- 
tions. Under the influence of atropin the heart-rate 
is increased by paralysis of the vagi. Talley states 
that a hypodermic injection of from 1/50 to 1/25 grain 
of atropin produces the same paralytic and rapid heart 
effect in man. He advises the use of 1/25 grain of 



#il 



346 HEART BLOCK 

atropin in robust males, and 1/50 grain in females 
and in less robust males, and he has seen no serious 
trouble occur from such injections. The throat is of 
course dry, and the eyesight interfered with for a 
day or more, but Talley has not seen even insomnia 
occur, to say nothing of nervous excitation or delirium. 
Theoretically, however, before such atropin dosage, an 
idiosyncrasy against belladonna should be determined. 
The value of such an injection rests on the fact 
that atropin thus injected will increase the normal 
heart from thirty to forty beats a minute, and Talley 
believes that if the heart-beat is increased only twenty 
or less, if the patient has not been suffering from an 
exhausting disease, it shows "a degenerative process 
in the cardiac tissue which makes the outlook for 
improvement under treatment unpromising." He 
also believes that when the heart in auricular fibrilla- 
tion is increased the normal amount or more than 
normal, the progress is good. He still further advises 
in auricular fibrillation an injection of atropin before 
digitalis has been administered, and another after 
digitalis is thoroughly acting. Comparison of the find- 
ings after these two injections will determine which 
factor, vagal or cardiac tissue, is the greater in the 
condition present. The patients with a large cardiac 
factor are the ones who may be more improved by the 
digitalis treatment than those in whom the fibrillation 
is caused by vagus disturbance. 

HEART BLOCK 

Complete heart block is due to pathologic changes 
affecting the system of fibers whose function it is to 
convey from the auricles the stimulus which causes 
normal ventricular contraction. Gummas, calcified 
plaques, or tumors may press on or invade that part 
of the auriculoventricular conducting system known 
as the bundle of His. Fibrosis, fatty degeneration, 
infarcts and inflammatory changes occurring in the 
bundle of His and perhaps other portions of the con- 
ducting system may also produce heart block. Incom- 
plete heart block, in which the relation of auricular 
to ventricular rhythm is partially retained, may be due 
to less extensive changes in the auriculoventricular 



HEART BLOCK 347 

system, resulting from acute infections such as pneu- 
monia, diphtheria, rheumatism, typhoid fever or sepsis ; 
from lesions of the medulla oblongata or vagus, and 
from overdosage with digitalis. It is probable that 
many deaths in acute infections are due to some form 
of heart block, and are caused by inflammatory swell- 
ing of the fibers of the auriculoventricular system. 

Patients with heart block may present no symptoms 
except slow pulse and independent rhythm of auricles 
and ventricles. This difference in rhythm is deter- 
mined by comparing the number of pulsations of the 
jugular veins per minute, as observed in the neck, 
with the radial pulse or the ventricular beat as made 
out at the heart. Syncopal attacks, completing the pic- 
ture of the Adams-Stokes syndrome, may occur at 
the onset of complete heart block or at any time after 
this condition has become established. 

If during a syncopal attack, the ventricles remain 
inactive for from fifteen to twenty seconds, muscular 
twitchings simulating an epileptiform seizure occur. 
If the ventricles are inactive for much longer than 
twenty seconds, death generally results. In some cases 
of complete heart block in which the ventricles beat 
with their own slow rhythm, independently of the 
auricles, the syncopal attacks may be absent for many 
years. 

Antisyphilitic treatment will greatly improve or cure 
those cases of heart block which are syphilitic in 
origin, in which the conducting system has not been 
completely destroyed. A Wassermann test should, 
therefore, always be made. In cases due to other 
causes, drug treatment offers relatively little. Digitalis, 
since it tends to slow still further the ventricular rate, 
should be withheld except in cases of long standing 
which have become decompensated owing to myo- 
cardial disease. Atropin may be used in the attack, 
but many who have given special study to the action of 
drugs in these cases question its value. Rest is impor- 
tant, especially in the cases occurring during acute 
infections. 



DISTURBANCES OF THE BLOOD 
AND BLOOD-MAKING ORGANS 



ANEMIA 

In the conditions characterized by a reduction of the 
oxidizing power of the blood we distinguish two prin- 
cipal varieties. In one of these the corpuscles are only 
moderately affected, but are less efficient oxidizing 
agents because they contain a deficient amount of 
hemoglobin. The number of red cells is only moder- 
ately reduced, but the functional power of each cell 
is far below the normal. The blood when examined by 
laboratory methods is found to have a low color index. 
To determine this it is necessary to estimate the num- 
ber of red corpuscles in a cubic millimeter. This fig- 
ure is then compared with 5,000,000, the average num- 
ber of red corpuscles in a cubic millimeter of blood 
of a normal person, the result representing the per- 
centage of. corpuscle. This percentage is made the 
denominator and the percentage of hemoglobin the 
numerator and the resulting fraction is the color index. 

In chlorosis and secondary anemias the color index 
is low; in pernicious anemia the color index is high 
although the total amount of hemoglobin is much 
reduced. In pernicious anemia many corpuscles have 
been destroyed but the individual corpuscle carries 
more than the average charge of hemoglobin. Having 
fixed the type of anemia it is necessary to search for 
any etiologic factor which may favor the reduction of 
the corpuscles or make them poor in hemoglobin. Any 
loss of blood if often repeated or habitual is likely to 
lead to a chlorosis or may so act on the blood-making 
organs as to transform the type of the disease into the 
pernicious form. Care should be taken to exclude 
wasting of cachectic diseases which frequently lead to 
secondary anemias which may be incurable until the 
primary affection is removed. Intestinal worms, par- 
ticularly hookworm and bothrioccphalus lotus fre- 
quently cause anemia partly by the repeated drawing 



ANEMIA 349 

of blood, and partly by the toxins produced by the 
worm and absorbed into the bloodstream. Other poi- 
sons, either extraneous or autogenous, may produce a 
like effect. 

The first step in treatment after removing any dis- 
coverable cause is to place the patient under the best 
hygienic conditions and afford as nourishing diet as 
possible. 

In combating the anemia, of greatest importance is 
the improvement of the hygienic condition of the 
patient, fresh air, sunlight, moderate exercise, and 
deep inhalation to increase the absorption of oxygen 
and the carbon dioxid elimination. The diet should 
be based on the intestinal condition, being the most 
nutritious and of the kind that can best be digested. 
The constipation should, of course, be combated, and 
most important of all, gastro-intestinal fermentation 
and intoxication, as evidenced by the finding of indi- 
can and sulphates in the urine, should be prevented. 
Various hydrotherapeutic measures, electrotherapy; 
electric light baths, massage and vibratory treatments 
may be of advantage. There can be no question of the 
advantages of fresh air and sunlight to patients suffer- 
ing from anemia, and there could be no better treat- 
ment than the open-air sanatorium treatment advo- 
cated for tuberculosis for these anemic patients. 
Patients who can not take the rest, sunshine and fresh- 
air cure improve with iron, and they will improve as 
much with an inorganic iron as with any organic iron. 
The mistake has been that too much iron is adminis- 
tered, hence some peptonate or albuminate or other 
organic iron has been said to be better tolerated. The 
mistake has been that the dose of the inorganic iron 
was not small enough. Very little is needed to satisfy 
the economy for iron. A small dose of the tincture of 
the chlorid of iron, or the reduced iron in tablet or 
capsule, or the pill of the carbonate of iron (Blaud), 
or the saccharated oxid of iron present a variety of 
inorganic irons sufficient to meet any indication. The 
multitude of other iron preparations is not needed and 
is superfluous. 



350 TREATMENT OF CHLOROSIS 

DETAILS OF TREATMENT IN CHLOROSIS 

In .chlorosis, so generally accompanied as it is with 
amenorrhea, thyroid substance may be given in small 
doses, as : 

gm. 
ty Glandularum thyroidearum 

siccarum 3\ or gr. xlv 

Fac capsulas 20 (dry). 

Sig. : One capsule, three times a day, after meals. 

Or: 

gm. 

1^ Glandularum thyroidearum | 

siccarum 2| or aa, gr. xxx 

Ferri reducti 2| 

M. et fac capsulas 20 (dry). 

Sig. : One capsule, three times a day, after meals. 

Occasionally cases of chlorosis resist iron and 
improve only after they have been kept in bed for a 
number of weeks. In some of these recovery is 
hastened by arsenic used as directed for pernicious 
anemia. 

In convalescence from chlorosis iron should be con- 
tinued in small doses for from three to six months. 

Iron may be given as follows : 

c.c. 

I£ Tincture ferri chloridi 5| A3 iss 

Syrupi acidi citrici 25 1 or AS i 

Aquae ad 100| ad A3 iv 

M. et Sig. : A teaspoonful, in water, three times a day, 
after meals. 

Or: 

gm. 

R Ferri reducti 2| or gr. xxx 

Fac capsulas 20 (dry). 

Sig. : One capsule, three times a day, after meals. 

Or: 

F£ Pilulas ferri carbonatis. (Blaud) No. 20. 
Sig.: One pill, three times a day, after meals. 

Or: 

gm. 

ty Strychnine sulphatis 02 gr. ¥3 

Ferri reducti 1 or gr. xv 

Quinine sulphatis 2 gr. xxx 

M. et fac capsulas 20 (dry). 

Sig.: One capsule, three times a day, after meals. 



PERNICIOUS ANEMIA 351 

Or: 

gm. 

Pp Arseni trioxidi 102 

Strychninae sulphatis 02 or aa, gr. ^ 

Ferri reducti 1 1 gr. xv 

Quininae sulphatis 2| gr. xxx 

M. et fac capsulas 20 (dry). 

Sig. : One capsule, three times a day, after meals. 

Or: 

gm. 

R Ferri reducti 1 1 or gr. xv 

Salicini 10 1 3 iiss 

M. et fac konseal. 20. 

Sig. : One wafer three times a day, before meals. 

PERNICIOUS ANEMIA 

The treatment of pernicious anemia must be con- 
ducted on the same principles as govern simple anemia 
except that it is generally recognized that iron is 
practically useless in this form of the disease. Hirsch- 
feld says that it is generally possible to find some 
preparation of iron that the patient can take, but 
arsenic is useful when the number of blood corpuscles 
is much below normal and there is little response to 
iron. Milk contains extremely little iron, so it need 
not be forced on the anemic as is often done. Small 
amounts of alcohol have a stimulating action on some 
anemic patients while others are unable to stand it. 
There is no deficiency in iron in pernicious anemia, 
but with repeated courses of arsenic it is possible 
sometimes to keep patients in good condition for years, 
even sometimes retaining their earning capacity. The 
patient should be kept under constant supervision so 
that the arsenic can be promptly resumed at the first 
signs of a relapse ; iron may then prove useful also 
when the arsenic fails. In pernicious anemia, hydro- 
chloric acid and pepsin must be given persistently. 
Transfusion of blood has sometimes done service but 
never realized a cure. 

In a considerable number of cases reported within 
the last two years splenectomy has been followed by 
immediate improvement and in some cases by such 
permanent results as to lead clinicians to adopt it as a 
measure of much promise. The results, however, do 



352 ARSENIC IN PERNICIOUS ANEMIA 

not indicate a cure of the disease as the blood picture 
still shows the characteristics of pernicious anemia. 

In giving arsenic for this disease Cabot advises to 
begin with a dose of two minims of Fowler's solution, 
liquor potassii arsenitis, well diluted, three times a 
day and gradually increase until the patient is taking 
15 minims three times daily. The drug may be given 
in pill form commencing with 0.6 mg. (1/100 grain) 
and increasing according to the patient's tolerance. 
When symptoms of intolerance appear the medicine 
should be suspended until the symptoms disappear 
wdien the treatment should be resumed. In Cabot's 
experience atoxyl, sodium cacodylate, and similar 
preparations present no advantage over the ordinary 
forms of arsenic. Cabot has in some cases given laxa- 
tives in doses just sufficient to produce two or three 
loose movements daily. He has not determined 
whether the good results are to be interpreted as 
instances of post hoc or propter hoc. 

In large doses, the Roentgen rays have a destructive 
action on the bone marrow, but in small doses they 
merely stimulate it to better functioning. This at 
least is what Vaquez and Aubertin conclude from the 
favorable results of Roentgen exposures in a case of 
severe anemia probably the result of long, mild car- 
bon monoxid poisoning. In several cases cited it was 
demonstrated that benefit may be expected when the 
blood marrow is still capable of responding to the 
stimulation. When it has degenerated beyond this; 
nothing can be hoped from the treatment. The out- 
look can be determined by examining the blood repeat- 
edly during the course of exposures. If the num- 
bers of nucleated cells increase, improvement may be 
counted on, but if the number of nucleated cells does 
not vary, the prognosis is grave. The radiotherapy 
seems to act in the same way as arsenic. In cases of 
mild anemia other measures seem to deserve the pref- 
erence, although Grego has reported excellent results 
in two cases of neurasthenia with chloro-anemia given 
2.5 H units at three-day intervals for three weeks. 
Similar benefit was realized in a case of anemia from 
excessive loss of blood. With these small doses the 
reds and hemoglobin percentage increased without any 



LEUKEMIA 353 

drop in the number of whites. Vaquez and Aubertin 
applied the rays with the same technic as for myeloid 
leukemia, especially to the knees, shoulders and elbows, 
and occasionally, the sternum. The rays are filtered 
through 2 or 4 mm. of aluminum. In one case the first 
dose was too large (18 H units scattered over the 
different epiphyses of the long bones), and the imme- 
diate result was a temporary aggravation of the 
anemia. 

LEUKEMIA 

This mysterious disease, whose cause is not yet 
accurately determined, is characterized by persisting 
increases in the white blood corpuscles. Two forms 
are known, the splenomyelogenous, in which there is 
enlargement of the spleen and tenderness over the 
long bones and sternum, and perhaps enlargement of 
the lymph glands, and the lymphatic type, in which 
the enlargement of the lymph glands is of greatest 
significance, the spleen increase being of secondary 
importance. 

In the splenic type there is a large increase in 
myelocytes. The white corpuscles as a whole are 
increased usually exceeding 150,000 per cubic centi- 
meter. The polynuclear forms are greatly increased 
and eosinophils and mast cells appear in much greater 
number than normally. 

In the lymphatic type, the number of lymphocytes is 
greatly increased, forming 80 to 90 per cent, of the 
whole. In some cases the total number of white cells 
is not increased, but the proportion of lymphocytes is 
much greater than normally. 

The onset of the disease is insidious, among early 
symptoms being the splenic hypertrophy, enlargement 
of the superficial lymph glands, pallor, anemia and 
dyspnea. Local hemorrhages may appear externally 
or there may be hemorrhages of the internal organs. 
An irregular temperature with periods of pyrexia is 
not unusual. Gastro-intestinal upsets with nausea, 
vomiting and diarrhea also occur. In the acute forms 
of the disease death may occur in from four to six 
weeks. 

Hahn (Therap. Monatsh., August, 1914, p. 452) 
believes that a vigorous course of treatment is not 



354 BENZOL IN LEUKEMIA 

indicated as a rule unless there is progressing anemia, 
distressing leukemia tumors or the whites are increas- 
ing beyond measure. The reason for holding back 
with energetic treatment is on account of the acute, 
almost explosive, aggravation of the condition which 
has occurred in many cases when all seemed to be 
going exceptionally well under treatment. The relapse 
then may prove far worse than the original trouble for 
which the treatment was started. 

The Roentgen rays seem to check the growth of the 
hyperplastic white-corpuscle-producing tissues, but 
overdosage may prove fatal, and too small doses may 
actually overstimulate these tissues : In Decastello's 
case of chronic myelosis the whites dropped after three 
mild exposures from 720,000 to 400 with 0.9 per cent, 
neutrophils and the patient died from hemorrhages. 
Schwarz has reported disastrous results from stimula- 
tion of functioning by minute doses. In this group 
belong the cases of leukemia developing in professional 
roentgenologists ; Heinecke has recently compiled six 
cases of this kind. Hahn advises systematic exposure 
of every accessible gland in the lymphatic form, but 
with myelogenous leukemia exposure of the enlarged 
spleen alone answers the purpose. In rebellious cases 
and recurrences he has witnessed benefit from expos- 
ing the long bones of the legs between the series of 
other exposures. He noted a marked improvement 
in the symptoms and general health in 75 per cent, of 
his cases, while the others were not influenced (6 in 
23 cases). Beclere has reported no failure in his 
12"lymphatic and 93 myelogenous cases. Radio-active 
substances fail in about 20 per cent, of the cases, 
according to the literature to date. The action and 
effect seem to be about the same as with the Roentgen 
rays ; the lymphatic form seems to be less ame- 
nable to the Roentgen-ray reaction and recurrence is 
inevitable. 

Benzol is commended by some and denounced by 
others. It certainly should not be given with disease 
of the liver or kidneys, or with catarrhal intestinal 
trouble, and it should be suspended when the leuko- 
cytes have dropped to 20,000 or 25,000, before the> 
have got down to normal figures. Hahn's experience 



BENZOL IN LEUKEMIA 355 

suggests the advantage of changing from one method 
of treatment to another; one seems to pave the way 
for a better utilization of another, while both can be 
applied with lesser dosage, possibly commencing with 
the Roentgen rays and continuing with benzol, not 
giving above 1 gm. a day of the latter. If myeloblasts 
appear in large numbers under Roentgen treatment he 
changes to thorium X and follows with a vigorous 
course of arsenic. When to start treatment again 
with recurrence is still a question. It is his practice 
to keep up the Roentgen exposures after subsidence of 
symptoms, giving every week or two a fraction of an 
erythem dose, and lately has been giving occasionally 
0.5 or 1 gm. of benzol a day, carefully supervising the 
liver and kidney functioning, and resorting to vigorous 
measures at the first signs of any flaring up of the 
process. With leukemia, myelosis and lymphadenosis 
it is better to hold back from vigorous measures on 
account of the danger of exacerbation unless one's 
hand is forced; then arsenic should be given a trial 
first. With acute leukemia all treatment seems to be 
hopeless, but as it is not always possible to differentiate 
the acute form, thorium X plus a vigorous course of 
arsenic should be tried. 

Selling (Bull. Johns Hopkins Hosp., 1910, xxi, p. 
33) showed that in rabbits benzol acted as an intense 
poison for the white cells. This fact was confirmed 
by many observers, but von Koranyi (Berl. klin. 
Wchnschr., 1912, xxii, p. 1357) first used benzene in 
the treatment of leukemia. Since his original article 
over forty original reports have appeared in the liter- 
ature. All observations agree that the administration 
of benzene produces a marked rapid reduction of 
leukocytes, but the permanency of the improvement is 
not yet established. The benzol used enterically is 
best given with an equal volume of olive oil in hard 
gelatin capsules which may be first coated with keratin 
and salol before administration. It seems advisable 
to begin with a dosage of 5 minims of benzene three 
or four times a day and increase over a period of 
four weeks up to 30 minims three times a day. 



356 HODGKIN'S DISEASE 

The coincident administration of drugs to overcome 
anemia and the gastro-intestinal upsets is of course 
advisable. 

Surgically, removal of the spleen has been performed 
in these cases but with no definite promise of perma- 
nent cure. 

HODGKIN'S DISEASE 

The etiology of Hodgkin's disease has only recently 
been determined. This condition may now be defined 
tentatively as a non-contagious but infectious granulo- 
matous process due to the Bacillus Hodgkini. Once 
established, there is little tendency to spontaneous 
recovery in this disease. Fischer (Deutsch. Ztschr. f. 
Chir. y 1901, xxiv, p. 104) was unable to find the rec- 
ords of a single permanent cure. In 1913 a number of 
observers were able to grow a pleomorphic diphtheroid 
organism, gram-positive, in pure culture from the tis- 
sues in this disease, and its introduction into animals 
resulted in establishing a series of similar changes in 
these animals. The disease manifests itself by a lym- 
phangitis, perilymphangitis, and lymphandenitis. In 
the early stages the process is local, though an increase 
in the lymphoid cells of the blood is apparent. In the 
later stages there are definite toxemia and anemia, and 
still later with wide dissemination, edema, dysphagia, 
etc. In a complete study of this subject Bunting and 
Yates (Jour. A. M. A., June, 1915) state that the 
course of the disease depends on the relative virulence 
of the infection. In the acute forms death may result 
in two to four months and in the more chronic forms 
life may be prolonged up to five years. One of the 
most characteristic features of the disease is the alter- 
nate periods of exacerbation and remission in the inten- 
sity of the process. During such remissions the treat- 
ment then in use is often given credit for the improve- 
ment. 

BLOOD PICTURE 

There are two types, an early and a late, showing 
a constant increase in the number of platelets with 
abnormally large forms and either a relative or abso- 
lute increase in the so-called transitional cells. In 
the early type the leukocytes are usually less than ten 



TREATMENT OF HODGKIN'S DISEASE 357 

thousand ; the lymphocytes are slightly above normal. 
In the late type there is a leukocytosis which may reach 
one hundred thousand, and the lymphocytes are 
reduced as low as 5 per cent. The transitional type 
may be above 8 per cent., the neutrophils being rela- 
tively increased to a percentage of from 75 to 92. 

TREATMENT 

The treatment is discussed by Bunting and Yates 
under five heads : Where the involvement is primarily 
cervical, even if the tonsils appear normal, a complete 
pericapsular tonsillectomy is indicated. If the primary 
glandular involvement is extra cervical, the source of 
infection must be found and the suspicious lesions 
appropriately treated. 

Excision of the cervical glands should be done as 
early as possible. Axillary dissections should be as 
extensive and as thorough as the cervical. It may be 
necessary to extirpate inguinal glands, as they are some- 
times primarily involved. In later stages of the dis- 
ease it is often difficult to make these severe dissections. 

Roentgen-ray treatment has often given rise to 
marked improvement, although recurrences seem 
inevitable under this treatment alone. 

It is necessary to develop the hygiene of the patient 
almost to perfection. Tonics may be indicated, iron 
and arsenic being preferable. Salvarsan has been used 
in these cases, but there are as yet no definite cures 
reported. Benzene also has been given, but with no 
definite promise of success. 

The use of vaccines seems rational, and both encour- 
aging and discouraging results followed the use of this 
method of treatment. . 

The patients should be examined at regular inter- 
vals, under various forms of treatment, to determine 
how they progress and whether they are about to 
develop a new exacerbation. The prognosis should 
always be extremely guarded. 



DISTURBANCES OF THE THYROID 



HYPERTHYROIDISM 

The etiology of hyperthyroidism is not yet deter- 
mined. The work of Rosenow, Billings and others is 
significant. Rosenow has isolated an anaerobic Gram 
positive diplobacillus which at times takes on a coccus 
form from about 90 per cent, of cases of exophthalmic 
goiter in man. He has isolated a similar organism 
from two thirds of the dog goiters examined. This 
organism was infrequently found in the thyroid glands 
of dogs in which there were no demonstrable patho- 
logic changes. B. Welchii, a hemolytic staphylococ- 
cus and a nonhemolytic streptococcus were also found 
in some of the thyroids examined, but these may have 
been contaminations. There are numerous reports in 
the literature of cases of hyperthyroidism following 
acute or chronic infections such as tonsillitis, sinusitis, 
arthritis and salpingitis. These facts make it seem 
likely that hyperthyroidism, like arthritis, endocarditis 
and nephritis, is due to metastatic infection of the 
thyroid gland. Billings has reported a series of cases 
of exophthalmic goiter which were treated by removal 
of chronic foci of infection. The results in these 
cases were striking and apparently give clinical proof 
of the infectious nature of the disease. 

TREATMENT 

The treatment of hyperthyroidism is then based on 
two main factors : first, alleviation of symptoms by the 
methods that have been in use, and second, removal 
of the foci of infection which may be responsible. In 
the milder and incipient cases removal of the focus 
alone may be sufficient. Indeed, in some of the more 
severe cases in Billings' series this was the only thera- 
peutic measure used as the patient refused to remain 
at rest even when in the hospital, and yet many 
patients made a complete clinical recovery. It is, 
however, better to have rest in bed, freedom from all 



DIET IN HYPERTHYROIDISM 359 

excitement, and improved general hygienic conditions 
for a few days before and after subjecting the patient 
even to such minor operations as tonsillectomy or 
extraction of teeth. 

Rest. — In the treatment of Graves' disease some 
of the most important general factors are freedom 
from mental and physical fatigue, and from all excite- 
ment. Rest in bed is the best method of obtaining this, 
but this is necessary only in the more severe cases. 
Cessation of work, and rest at home are in many cases 
sufficient. Exercise should be partaken in, but with 
moderation, especially in those cases in which there is 
more or less tachycardia; otherwise, permanent injury 
to the heart may result. Rest in bed with an ice pack 
or coil over the precordium is perhaps the best treat- 
ment for the rapid heart of hyperthyroidism. The 
digitalis preparations have practically no effect on this 
type of tachycardia; indeed, digitalis poisoning may 
result without any slowing of the pulse. 

Excitability. — For the general nervous excitability, 
rest in bed is again the best treatment. Bromids may 
be used, but are apt to increase the general debility of 
the patient. Opiates are contraindicated even though 
they always reduce thyroid secretion. If used, it 
should be with great caution as serious results may 
ensue after even small doses of any of the prepara- 
tions or alkaloids of opium. About the only drugs 
that seem to have any beneficial effect on hyperthyroid- 
ism are the glycerophosphates of lime and soda and 
quinin hydrobromid. Symptoms of cinchonism may 
be noted when the latter is given in 0.30 gm. (5 grain) 
doses, but these soon disappear. The hydrobromid is 
much more efficacious than any of the other salts of 
quinin. For the extreme nervousness of acute hyper- 
thyroidism, a continuous water bath is very beneficial 
and much less injurious than the bromids and opiates 
that would otherwise be needed. 

Diet. — The diet in mild cases should consist of sim- 
ple foods the variety of which need not be limited 
except that it is better to use meat very moderately. 
Tea and coffee should of course be omitted. Caffein, 
strychnin and other general stimulants are contra- 
indicated as they tend to aggravate the nervous symp- 



360 SERUMS IN HYPERTHYROIDISM 

toms. In the more severe cases a meat free, soft or 
even liquid, diet is advisable. The diet in all cases 
should be moderate in amount and of a character that 
will keep the bowels regulated. If the diet does not do 
this any mild cathartics may be given as needed. In 
many cases of Graves' disease there is a decreased 
sugar tolerance and consequently there may be a gly- 
cosuria. This should be controlled by the diet. 

Infective Foci. — As already stated, an important 
factor in the treatment of hyperthyroidism is the 
removal of the foci of infection. With this in mind, 
teeth, tonsils, sinuses, gallbladder, appendix, genital 
organs, etc., should all be carefully studied and then 
treated as necessary to clear up any infection. The 
importance of completely clearing up foci of infection 
is illustrated by the way in which symptoms persist 
even after partial thyroidectomy when foci of infec- 
tion remain unattended to. 

Serums. — S. P. Beebe of Cornell has recommended 
the use of a serum in the treatment of exophthalmic 
goiter. He states that the serum has been used in over 
3,000 cases with the following results : Fifty per cent. 
of the patients have been cured in the sense that they 
are strong and able to meet all the demands made on 
them. Thirty per cent, of the patients treated show a 
very marked improvement, to such a degree that they 
meet all the usual demands of life without undue 
reaction. Under unusual physical or emotional strain 
they react more than normal persons do. The two 
symptoms which are most evident with them are a 
gland larger than normal, and in many cases a mild 
exophthalmos. Some of this group ultimately improve 
to a point permitting them to be called well. The 
remaining 20 per cent, includes those who have not 
been so markedly benefited, those who have been oper- 
ated on, those who have not been benefited and those 
in whom the disease has proved fatal. The percentage 
of fatal cases in patients who have had serum treat- 
ment for a period of six months is very small. The 
serum used was prepared from the serum of Belgian 
hares after the animals had been injected with serum 
obtained from exophthalmic goiter thyroids. Lately, 
Dr. Beebe has stated his belief that extracts of human 



THYMUS IN HYPERTHYROIDISM 361 

thyroids, carefully prepared and administered hypo 
dermatically, are by far the best for the human sub- 
ject. By careful analysis he has come to the conclu- 
sion that any portion of the prepared protein that 
contains about 0.0034 of iodin represents 1 gram of 
the active protein. He prepares tablets of different 
strengths representing 1, 2, and 5 per cent. He under- 
stands that a 1 per cent, tablet means that 1 per cent, 
of the dried weight of the tablet is made up of the 
purified thyroid protein. For hypodermic use he 
makes various strengths standardized on the iodin 
basis, put up in sealed glass tubes. 

Specific Preparations. — Iodin, iodids, thyroid extract 
and the crystalline active principles of Kendall's group 
described later generally aggravate the symptoms and 
so are contraindicated. The constituents of Kendall's 
Group B would be beneficial in those cases of exoph- 
thalmic goiter in which there are some of the skin 
changes of hypothyroidism. There are a number of 
preparations on the market that are derived from 
thyroidectomized animals which seem to be beneficial 
in some cases. The extract of thymus, epinephrin, and 
pituitary extract sometimes seem to alleviate the symp- 
toms. 

Roentgen Ray. — The Roentgen ray has been used 
with excellent results. It should, however, not be 
used indiscriminately as, if not administered by a 
skilled radiotherapist, serious injury may result. The 
effect of radium on goiter is quite similar to that of 
the Roentgen ray. 

Surgery. — Surgery is at present the most used thera- 
peutic agent in the treatment of hyperthyroidism. 
Ligation of the superior thyroid arteries and partial 
thyroidectomy are both of great value in alleviating 
symptoms. It is, however, generally recognized that 
relatively few cases of exophthalmic goiter are actually 
permanently cured by surgery. Some symptoms per- 
sist or recur, if only when the patient is fatigued or 
excited. Injections of boiling water, quinin and urea 
hydrochloric!, etc., all produce the same results as par- 
tial thyroidectomy by destroying part of the gland. 

Thymus. — Some cases of exophthalmic goiter are 
complicated by an enlargement of the thymus. Indeed, 



L 



362 TREATMENT OF HYPERTHYROIDISM 

it seems that in certain cases in which there are quite 
marked symptoms with but little enlargement of the 
thyroid that the thymus is the cause of the disease. 
Matti's research and study of the literature confirm 
that the thymus is often directly concerned in the pro- 
duction of exophthalmic goiter. The monopoly hith- 
erto enjoyed by the thyroid is at an end. The adrenals 
often are insufficient in this disease and epinephrin 
may be indicated to prepare the patient for operative 
treatment. The changes in the thymus in exophthalmic 
goiter are not to compensate for the thyroid, but are 
directly coordinated with and parallel to the changes 
in the thyroid. The thymic hyperplasia greatly 
increases the risk in surgical treatment of the thyroid. 
The genital organs are generally either directly or 
indirectly involved in exophthalmic goiter, as is shown 
by the irregularities in menstruation that are common. 
The glycosuria that is sometimes present is probably 
due to deranged metabolism due to altered thyroid 
secretion, but may be due to an infection of the pan- 
creas by an organism similar to the one effecting the 
thyroid. 

SUMMARY 

Weiland (Therap. der Gegenw. y 1915, lvi, No. 5), 
in a summary of views on the treatment of exophthal- 
mic goiter, remarks that men trained to think surgically 
are apt to regard exophthalmic goiter altogether too 
much from a surgical standpoint, and internists view it 
from the internal medicine standpoint, while men who 
have had much experience are liable to follow the 
method of treatment with which they have been most 
successful in the past, without due regard to whether 
the present case fits into the frame of the former 
cases. He points out the necessity, with internal mea- 
sures, of supplementing general treatment both physi- 
cal and psychical with a diet to influence the metabolic 
disturbances and specific treatment of the thyroid 
itself. Measures in all these directions are called for 
usually in every case, from the mildest thyrotoxicosis 
to the severest type of exophthalmic goiter. 

Disturbance from perverted thyroid functioning 
develops very insidiously as a rule. At first there are 
symptoms of a general nervous disturbance ; the tern- 



TREATMENT OF HYPERTHYROIDISM 363 

perature is normal unless there is an underlying tuber- 
culosis. The proportion of patients restored to full 
earning capacity is larger under operative than under 
medical measures, but the latter perseveringly applied 
restore full earning capacity in a larger percentage 
than is generally realized. Still greater benefit can 
be realized, if roentgenotherapy is used to supplement 
other measures, with or without an operation. Wei- 
land states that he has never witnessed a case in which 
every one of the symptoms had entirely retrogressed 
under surgical or medical measures, or both, but we are 
justified in calling the case cured when the patient feels 
strong and well, the heart behaves normally, and there 
is no further restlessness, tremor or abnormal sweat- 
ing, and full earning capacity is restored. 

The first thing in treatment is to ensure physical and 
mental repose ; a few days in bed benefits, in mild cases, 
as much as a few weeks in the severer forms. This 
repose should not be disturbed by dietetic or other 
restrictions, but should be utilized to tranquilize the 
patient's mind and obtain his cooperation in the efforts 
for recovery. The treatment at this time should be 
the same as for nervous prostration or convalescence 
from any sickness except that sedatives may be 
required to overcome severe motor and psychic unrest. 
In the milder cases no drugs are needed. Arsenic is 
useful, but he never gives iron. The diarrhea or 
sweats disappear spontaneously as the general condi- 
tion improves. For several years it has been the prac- 
tice of Kiel to give sodium phosphate in every case 
of exophthalmic goiter, for reasons which Weiland 
enumerates, and it is regarded as an essential part of 
the treatment. It is given in daily doses of 3 or 4 gm. 
in a 10 per cent, solution. Digitalis is given only under 
the same indications and dosage as with organic disease 
of the heart. 

The diet should be that of forced feeding, training 
the patient to masticate and striving to tempt his appe- 
tite, making special use of carbohydrates and fat, 
possibly supplemented with some pancreas preparation. 
It is not necessary to push the forced feeding to 
bring the weight up to normal. Local applications of 
cold and electricity may relieve the tormenting symp- 



364 SIMPLE STRUMA OF THYROID 

toms from vascular goiters. He has not had favorable 
results from organotherapy of exophthalmic goiter, 
but has been much impressed with the benefit from 
Roentgen exposures. They can be applied in all forms 
of exophthalmic goiter. He used hard tubes, of Zy 2 
ma, with 16 x as the maximal dose, fractioned at two 
sittings with a few days' interval, repeating this for 
three or four months, with two and four weeks' inter- 
vals. 

If the weight and strength keep running down and 
the heart functioning growing worse, an operation 
should be recommended without delay, but otherwise 
not until after a thorough course of internal mea- 
sures. For operative treatment, the objective symp- 
toms form the criterion. Weiland in conclusion 
emphasizes that after operative treatment the patient 
requires medical oversight as much as after an opera- 
tion for gastric ulcer. 

Added to this, however, should be a statement as 
to the great importance of removing foci of infection 
and increasing individual resistance. 

SIMPLE STRUMA OF THE THYROID 
It is possible that the simple strumous hyperplasias 
of the thyroid are due to an infection similar to the 
one causing hyperthyroidism, but this has not been 
proved. The only cause for treating the colloid goiter 
which is causing no symptoms is to reduce the size of 
the gland as a goiter is unsightly. Some colloid goi- 
ters become large enough to interfere with deglutition 
and respiration : in such cases, of course, surgery is 
indicated. Iodin, iodids and thyroid extract are some- 
times effective in reducing the size of the gland. E. C. 
Kendall's active principle of the thyroid may prove of 
value in some of these cases. 

Removal of foci of infection may prove of value in 
the treatment of these goiters. If they are infectious, 
removal of the foci should at least stop further increase 
in size and also should make a change to the exoph- 
thalmic most unlikely. So, removal of foci of infec- 
tion is indicated even in the simple strumous goiters. 
For the strumous goiters of puberty little or no 
treatment is needed as they usually disappear spon- 
taneously. 



USES OF THYROID 365 

HYPOTHYROIDISM (HYPOSECRETION) 
Hyposecretion of the thyroid gland, the cause of 
which is not yet known, is present in the following con- 
ditions, either as a cause or as an accompanying com- 
plication : 

Chlorosis Epilepsy 

Amenorrhea Melancholia 

Obesity Slow growth in children 

Goiter Cretinism 

Eczema Adiposis dolorosa 

Hysteria (depressant forms) Lipomatosis 

Vomiting of pregnancy Myxedema 

Eclampsia Senility 

Typical symptoms of hypothyroidea are best recog- 
nized and studied in the adult female. If there is 
absolute absence of secretion, myxedema develops. A 
normally diminishing secretion, such as occurs after 
45 or 50 years of age, is shown by symptoms, the most 
evident being the addition of flesh, especially deposits 
of fat, a slowly increasing blood-pressure, and a 
gradual development of connective tissue in various 
parts of the body. If this secretion diminishes nor- 
mally as age advances into old age, the skin begins to 
lose its nutrition and dries and wrinkles, with a ten- 
dency to the occurrence of eczemas. 

PRINCIPAL USES OF THYROID 

The absence of menstruation, after it has once 
developed, without pregnancy or acute or chronic dis- 
ease, may point to a diminution of the thyroid and 
ovarian secretions. If the patient is anemic, iron and 
ovarian extract should be the treatment. If the patient 
is not very anemic and tends to put on weight, thyroid 
extract may be used in the treatment. The dose of 
thyroid should be small, not more than 3 grains of the 
dried extract once a day. 

There has never been a satisfactory explanation of 
the condition of chlorosis. For some reason these 
patients do not metabolize the iron of their food. 
Large doses of iron always cure these patients. If 
these girls begin to menstruate normally the disease 
disappears, and thyroid seems to act as an efficient 
emmenagogue. 



366 INFANTILE OBESITY 

Infantile obesity is modified by small doses of thy- 
roid, and if recognized early the condition may be 
inhibited. The disturbance in metabolism that is most 
frequently improved by thyroid is obesity. Thyroid 
will probably cause loss of weight in every instance 
provided a sufficient amount is given, but at the same 
time there is a great nitrogenous loss, and there is 
always the danger of causing disturbances due to an 
increased amount of thyroid in the blood, some of 
which may be serious. It can cause faintness and loss 
of strength, and a debility which may not be recovered 
from in a considerable length of time. If weight is 
being added, especially in women, after 45, small doses 
of thyroid may prevent it. If the fat is already pres- 
ent, it may take considerable dosage to reduce it. The 
large doses which were once used for this purpose are 
not justifiable, and a patient under thyroid treatment 
for obesity should be very carefully watched, and the 
administration should cease as soon as any unpleasant 
symptoms appear. When weight is put on in younger 
life, especially in women, thyroid is the most efficient 
treatment, and the dose required is generally not large. 
The value of combining such treatment with a diet free 
from sugar and with a diminished amount of carbo- 
hydrates, and with physical exercise, should not be 
overlooked. The dose of thyroid should be 0.2 gm. 
(3 grains), at first three times a day for a. week, then 
twice, a day for another week, and after this once a day 
will probably be sufficient. To be sure that the thyroid 
is active, 0.25 gm. (4 grains) of sodium iodid should 
be administered once during each twenty-four hours 
The patient ma}' not begin to lose weight for at least 
two weeks, and after that some weight should be lost 
every week, and patients may lose weight even after 
the treatment has been stopped. The loss of two or 
three pounds a week should be considered sufficient 
and satisfactory. If the excessive weight is hereditary, 
or has persisted for years, the fat will again return on 
cessation of the treatment, and in these patients great 
loss of weight will not be caused by the treatment 
without the necessity for more thyroid being admin- 
istered than is safe. 



VOMITING OF PREGNANCY 367 

SIGNS OF HYPOSECRETION 

If undesirable fat begins to be deposited before 
the age of 40, unless there is a marked family ten- 
dency to such excessive weight, the thyroid is prob- 
ably undersecreting. If such deposits of fat occur on 
the hips, over and under the clavicles, on the upper 
arms, around the breasts in women, with a feeling of 
oppression, dyspnea on exertion, and especially if 
menstruation has ceased, the diagnosis is absolute, thai, 
the thyroid is secreting insufficiently. If this condition 
just described further develops, adiposis dolorosa is 
in evidence, the only difference being that of degree 
and that the fatty parts are painful. The thyroid is 
always found to contain a large amount of connective 
tissue and to be subsecreting in this disease. In the 
rare -instances of general and localized lipomatosis the 
thyroid is probably not perfectly active, although other 
signs of its inactivity may not be present. Thyroid 
will always improve the condition of the skin even if 
it does not inhibit the advance of the disease. 

Many eczemas of early childhood are often incorri- 
gible until minute doses of thyroid are administered. 
These are especially the type that occur around the 
orifices of the body, and when little fissures or cracks 
in the skin occur. The troublesome eczemas of old 
age often will not heal with local treatment until 
small doses of thyroid are added to that treatment, 
Sometimes the results obtained by such treatment of 
these patients is most satisfactory. 

Hysteria of the melancholic depressant type where 
there is apathy, unwillingness to talk, and general 
depression, may be improved and cured by the admin- 
istration of small doses of thyroid. The border-line 
between this kind of hysteria and beginning melan- 
cholia is hard to determine, but the cerebral stimula- 
tion caused by thyroid will sometimes prevent the 
development of insanity. Whether actual melancholic 
insanity is benefited by thyroid is doubtful, but it cer- 
tainly is a treatment sufficiently logical to be tried in 
every case. 

VOMITING OF PREGNANCY 

There have been many suppositions as to the cause 
of the persistent vomiting of pregnancy. It is c.er- 



368 • ECLAMPSIA 

tain that if the vomiting persists the patient develops 
an acidosis, and this cause alone may continue the con- 
dition or actually cause death. Whether it is purely 
reflex or whether there is a metabolic poisoning of the 
system of which vomiting is a consequence, it seems 
certain that any method that allows the mother to 
metabolize her food better, and eliminate the nitrogen 
excretory products properly, will be of benefit to her. 
Whether there is often or occasionally a subsecretion 
of the thyroid during the early months of pregnancy 
when vomiting is so likely to be in evidence is not 
known, but many instances have been reported in 
which the administration of small doses of thyroid 
has improved such a serious condition. It is certain 
that the thyroid will increase the nitrogenous output 
in the urine. It is also certain that the thyroid should 
hypersecrete during pregnancy. If it does not do so 
it is acting abnormally, and the vomiting of preg- 
nancy may be an indicator of such secretion. 

It is certainly advisable, when a woman has given 
birth to one or more children who have shown sub- 
thyroid activity, to administer to her thyroid gland 
substance during her next pregnancy. Such treatment 
is logical, and has been successful in producing healthy 
children. It is inadvisable to give small doses of thy- 
roid to a pregnant woman or if its results are unsatis- 
factory, small doses of iodid may be substituted, when 
it is decided that the patient's own thyroid is not 
secreting properly. 

ECLAMPSIA 

Many obstetricians now believe that one of the best 
treatments for eclampsia is thyroid. In instances in 
which it is successful the poisoning is probably a nitro- 
gen poisoning, and eclampsia can occur without serious 
kidney defect. When a pregnant woman is found to 
have signs of subsecretion of the thyroid she cer- 
tainly is in danger of eclampsia at parturition, and the 
previous administration of thyroid is certainly indi- 
cated. A dose of three grains a day, at least during the 
last month of pregnancy, is advisable. If eclampsia 
has developed, 1 gm. (15 grains) of thyroid should be 
given at once and repeated in two hours. 



MYXEDEMA . 369 

Epileptic attacks developing during some disturbance 
of menstruation, whether at the time of puberty or at 
the time of the menopause, and especially if repeated 
only at the times of the menstrual periods, just before 
or just after, or at the time when the menstrual period 
should occur and does not, shows that the cause has 
something to do with the thyroid. The thyroid gland 
hypersecretes normally at and before menstruation ; if 
it does not do so, something in the system cannot work 
as perfectly physiologically. In the kind of epi- 
lepsy just described thyroid is the treatment. It should 
be administered in small doses, 3 to 5 grains, daily 
(the size of the dose depending on the symptoms of 
the physiologic action of the thyroid), during the 
interval between the periods. When the attack is 
expected, for a day or two before, bromid treatment 
may be added. If the thyroid acts unpleasantly, caus- 
ing palpitation or loss of weight, it need'not be given 
throughout the whole four weeks of the interval, but 
may be omitted during the first two weeks. Many 
instances are on record in which this kind of epilepsy 
has been cured by such treatment. 

MYXEDEMA 

More or less complete insufficiency of the thyroid 
in adults causes myxedema. This is a rare disease in 
men, and occurs in more than 80 per cent, of all cases 
in women, and mostly in those who have borne chil- 
dren. It would seem from such statistical facts, that 
the gland is inclined to excessive atrophy because it 
has previously been stimulated, in women, from the 
periodicity of its increased secretion on account of 
menstruation, and from its overwork during preg- 
nancy. The treatment is thyroid ; all of the symptoms 
disappearing. The dose should not be large, but if for 
any reason the treatment is rapidly pushed, the patient 
should be in bed lest sudden heart failure occur from 
the large doses of thyroid. As soon as the patient 
improves, the dose should be reduced ; a dose of 3 
grains of the dried gland substance a day is sufficient, 
and even this may subsequently be given but every 
other day, or even less frequently. Sometimes the 
thyroid gland of such a patient may be stimulated or 



370 CRETINISM 

may recuperate, or perhaps a supernumerary thyroid 
may develop so that active thyroid medication is needed 
only intermittently. 

In operative myxedema in which the thyroid gland 
has been removed totally, or so much has been removed 
that the secretion of the remaining portion is insuffi- 
cient, or in some instances of true myxedema, in which 
the patient cannot live without continued thyroid treat- 
ment, transplantation or implantation of thyroid gland 
tissue into various organs of the body has been tried, 
sometimes with success. This same implantation has 
been tried in cretins, and there are records of success. 
The younger the patient, the more successful, perhaps, 
is the treatment, but the whole subject of such trans- 
plantation is as yet purely experimental. 

CRETINISM 

In cretinous children the thyroid is either absent, or, 
if present, contains a small amount of colloid material 
or is cystic, and there is almost entire absence of thy- 
roid secretion. The curative actionof thyroid in cre- 
tinism is a demonstrated fact, and the sooner the diag- 
nosis of cretinism is made, the greater the amount of 
success which will attend the use of thyroid. Unfor- 
tunately, the diagnosis of cretinism can rarely be made 
until the child is from 6 months to a year old, and if 
there is not total absence of thyroid secretion, an infan- 
tile myxedema cannot be determined until the child is 
2 or 3 years old. If a cretin or a patient with infan- 
tile myxedema is not treated until he is several years 
old the results of such treatment are much less satis- 
factory. The dose for an infant is not more than 
.065 gm. (1 grain) of the official thyroid powder, two 
or three times a day. If the cretin is older, the dose 
may be larger. Its unfavorable action is shown by 
increased cardiac rapidity and loss of appetite. Its 
favorable action is shown by a diminution of the myxe- 
dema ; in other words, the puffiness of the skin becomes 
less, and there is an actual loss of weight. The mental 
powers should increase, and the hair, nails, teeth and 
bones should grow normally. The thyroid feeding, 
as soon as improvement has positively taken place, 
should then be slightly diminished, and a smaller dose 



UNCLASSIFIED USES OF THYROID 371 

given daily for months and perhaps for years. If 
unpleasant symptoms of thyroid action occur, the thy- 
roid should be stopped for a week and then again 
begun at a smaller dose. 

UNCLASSIFIED USES OF THYROID 

Thyroid has been used with success in some instances 
of hemophilia and purpura hemorrhagica, as well as 
in the irregular hemorrhages of the menopause. 

It has been used in chronic rheumatism as well as 
in arthritis deformans, and has many times been suc- 
cessful in gouty rheumatism, especially where the 
attacks showed a general disturbance of metabolism, 
such as at one time an asthmatic attack, at another an 
indigestion attack, and at another a typical gouty joint 
attack. Small doses given for a considerable time are 
often successful in this kind of metabolic disturbance. 

Sometimes thyroid acts as a diuretic, and it certainly 
is an antidote to nitrogenous poisoning in insufficient 
kidney action. Even uremic convulsions are some- 
times kept in abeyance by the administration of thy- 
roid. During a uremic attack the dose of thyroid 
should be large, as 10 grains of the dried extract three 
times a day. Such treatment sometimes apparently 
prevents convulsions and in some instances seem to 
aid in saving life. 

Thyroid has been used in various skin diseases, 
sometimes with success. The indication seems to be' 
to stimulate extra secretion of the skin. If there is 
an acute inflammation or hyperemia, thyroid would 
not be indicated. Conditions in which it has been suc- 
cessful are the dry chronic eczemas, sometimes in 
psoriasis, ichthyosis, and in some instances of sclero- 
derma. 

If not otherwise contraindicated, whenever there is 
excessive connective tissue development in any organ 
— in other words, a sclerosis or cirrhosis — a small 
dose of thyroid daily is of benefit. The dose should be 
so small that it could not cause evident signs of its 
physiologic activity. In many of these instances small 
doses of iodid, given daily for long periods, may be of 
as much benefit. 



372 ADMINISTRATION OF THYROID 

Some clinicians have certified to, and even proved, 
in certain instances, the value of thyroid in inhibiting 
or causing resorption of carcinomatous growths. This 
is especially true of uterine carcinoma. The majority 
of investigators, however, have not found this treat- 
ment successful. 

THE ADMINISTRATION OF THYROID 

Unless thyroid is administered in large doses to com- 
bat an intoxication or toxemia, as in puerperal eclamp- 
sia or uremia, a therapeutic dose should cause no evi- 
dent symptoms. In other words, if thyroid is to be 
administered continuously for its continued physio- 
logic effect it should give no more symptoms than does 
the normal thyroid secretion. Large doses may cause 
nausea, dizziness, and, if quickly absorbed, faintness. 
There is probably no direct acute poisoning from thy- 
roid, although large amounts have been known to 
cause convulsions and even death from shock, i. c, 
by the toxic effect on the heart and the enormous vaso- 
dilator effect, as has been seen in operations for 
Graves' disease when the thyroid has been too much 
manipulated and a large amount of its secretion has 
been squeezed into the circulation. 

The treatment of acute thyroid intoxication would 
be the hypodermatic or intravenous use of epinephrin 
or other suprarenal vasopressor substance, the adminis- 
tration of atropin and strychnin. Possibly good treat- 
ment would be bleeding from one arm while physio- 
logic saline was tranfused into the other arm. 

Contraindications. — Any symptom similar to those 
of exophthalmic goiter should ordinarily prohibit the 
use of thyroid. Also, if during the administration of 
thyroid excessive nervousness, sleeplessness, palpita- 
tion, and loss of weight occur, the administration 
should be stopped. Ordinarily a poor condition of the 
circulation and a soft and weak pulse should prevent 
its use. Serious nervous and cerebral excitation 
should also ordinarily prevent its use. 

Official Preparation. — Glanduke thyroids siccse, 
desiccated thyroid glands, is a yellow powder prepared 
from the thyroid glands of sheep. It has a disagree- 
able, meaty smell, and is partially soluble in water. 



THYROID PREPARATIONS 373 

This preparation of course contains the active prin- 
ciple of the thyroid gland, but its activity depends on 
the amount of the iodin content, and this is variable. 
The dose varies from 0.03 gm. ( J / 2 grain) to 1 gm. 
(15 grains), depending on the frequency and the 
object for which it is used. Thyroid may also be 
obtained in tablets which vary in size and strength. 

Thyroidin is a standard preparation described in 
New and Nonofficial Remedies. 

KENDALl/s PREPARATION 

Kendall has isolated tw r o groups of active priniciples 
from the thyroid gland the qualities and characteristics 
of which he summarizes as follows : 

1. By an alkaline alcoholic hydrolysis, the thyroid 
proteins are broken into many simpler constituents. 
These may be separated into two groups : the acid 
insoluble compounds are designated Group A ; those 
acid soluble, Group B. 2. From Group A a pure 
crystalline compound, containing 60 per cent, of iodin, 
has been isolated. It appears to be di-iodo-di-hydroxy- 
indol. 3. Group B contains iodin in some unknown 
form of combination. It is a mixture containing 
amino-acid complexes and a low molecular weight. 
4. Administration of A produces in the dog and in the 
human being a rapid increase in pulse rate and vigor, 
and increase in metabolism and nervous irritability. 
This physiologic activity is produced by the compound 
containing iodin in all stages of purity up to and includ- 
ing its crystalline form. 5. Given in excess, toxic 
symptoms are produced. The amount of the iodin 
compound required to produce toxic effects is exceed- 
ingly small. 6. In exophthalmic goiter tw T o abnormal 
conditions exist. First, the secreting capacity of the 
gland is greatly increased and, second, the reservoir 
capacity of the gland is greatly decreased. The iodin 
compound plays an important role in the production of 
the symptoms of exophthalmic goiter. 7. The con- 
stituents of Group B produce no toxic symptoms, but 
in cases of cretinism, myxedema and certain skin con- 
ditions, they exert physiologic activity. 



374 ANTITHYROID PREPARATIONS 

ANTITHYROID PREPARATIONS 

Various antithyroid preparations may be obtained. 
These are of course indicated when there is too much 
thyroid secretion. One preparation is termed "thyroi- 
dectin," and is prepared from the blood of thyroidec- 
tomized animals. It is a reddish-brown powder, and 
may be obtained in capsules each of which contains 5 
grains. The dose is one to two capsules, three times 
a day. 

Moebius' antithyroidin is a serum obtained from the 
blood of thyroidectomized animals, the dose of which 
is from 2 to 10 drops, three times a day. 

The milk of thyroidectomized goats may be admin- 
istered fresh from the animal. 



DISEASES OF THE NERVOUS SYSTEM 



CHOREA 
Chorea, also known as chorea minor, Sydenham's 
disease or St. Vitus' dance, manifests itself by mus- 
cular movements, mental irritability, sleeplessness, 
troublesome dreams, and perhaps hallucinations. The 
most frequent age is from 5 to 15 years, and girls are 
affected three times as frequently as boys. Chorea 
is probably due to an infection and the frequency with 
which it follows inflammatory rheumatism, and 
chronic tonsillitis, as well as the common complica- 
tion of endocarditis would seem to indicate an organ- 
ism of the streptococcal series. In fact, Dick and 
others have been able to show that a relation does 
exist between focal infections with this type of organ- 
ism and chorea. 

TREATMENT 

As will ordinarily be noted, the child with chorea 
is anemic, restless, illy nourished — in fact, just the 
type to show a low resistance to infection. The pri- 
mary indication to be met, in view of this fact, and 
m view of the hyperirritability of the sensory-motor 
system, is the provision of rest. It may be well at the 
outset to insist on absolute rest in bed for a few days 
or weeks. The child should be shielded from sources 
of irritation such as school work, other children, a 
fretful mother, hard playing or even much walking. 
During the period of rest, massage and passive motion 
may be instituted to prevent too great disuse of mus- 
cles and secondary atrophy. 

The diet should depend on the acuteness of the 
symptoms, whether fever be present and in relation to 
the patients appetite. A goodly quantity of a good 
milk may be somewhat freely given. Meat should be 
allowed in small quantities only and such excitants as 
tea, coffee and alcohol should be absolutely interdicted. 

Hydrotherapeutic and physical methods are 
undoubtedly of great value in chorea. The warm 



376 TREATMENT OF CHOREA 

bath is sedative and may be given daily or every other 
day. When accompanied by systematic massage or 
graded exercises it may achieve markedly good effects. 

Needless to state, such cases should be thoroughly 
examined and local foci of infection such as carious 
teeth or diseased tonsils should be promptly eliminated. 
Furthermore such sources of continued irritation as 
phimosis, otitis media, worms, or adenoids should 
receive adequate attention. 

It has been suggested that some of these cases are 
stimulated by purely mental obsessions. An analysis 
of the mental processes with free questioning by a 
physician who has gained the patient's confidence may 
reveal such a hidden source and an adequate explana- 
tion may be of invaluable aid in clearing up the 
symptoms. 

MEDICINAL TREATMENT 

Arsenic, as Fowler's solution, has been a highly 
praised treatment for chorea and seems to succeed in 
many cases. The drug is given in small doses begin- 
ning with 2 minims, three times a day, and increas- 
ing 1 minim a day until the physiologic effect is 
obtained. This is manifested by a puffiness under the 
eyes or gastro-intestinal symptoms. If too long con- 
tinued there is a possibility of arsenical neuritis. 

The patient's bowels should be kept open and a 
fair elimination encouraged by the use of laxatives 
such as cascara and phenolphthalein. 

If the movements become violent or severe they 
should be checked by the use of a hypnotic, and 
chloral is generally recommended for this purpose 
in a dosage sufficient to cause sleep — perhaps 5 grains 
every four hours for a child of 6 or upward. 

The heart conditions should be studied and especial 
attention given to it during the administration of 
hypnotics, antipyretics or salicylates. 

Anemia may be combated with iron and arsenic, 
and in any event after the movements have ceased and 
the child is convalescent, iron may be required. 

Acetphenetidin and other antipyretics, as acetanilid, 
have been given in some cases of chorea with full 
success. 



EPILEPSY 377 

The rheumatic history of these cases points to the 
use of the salicylates in full doses. Various English 
observers have given as much as 90 to 120 grains a day 
of acetyl salicylic acid. This drug seems preferable to 
the salicylate of sodium. The following prescription 
has been recommended as a satisfactory method of 
administering large doses of the drug to children : 

gm. or c.c. 

I£ Acidi acetylsalicylici 8 3 iiss . 

Acaciae q. s. or 

Syrupi aurantii 25 A3 i 

Aquam chloroformi ad 100 fl5 iv 

M. et Sig. : A dessertspoonful, in water, every 4 hours. 
[This must be well shaken.] 

This dose is suitable for a child 6 to 8 years of 
age, but it should be increased for older children. 

A patient who has recovered from an acute chorea 
should be given an outdoor, quiet life for several 
months. School work should be absolutely prohibited. 
If the chorea has occurred about puberty in young- 
girls, all excitement and the strain of school life 
should generally be forbidden until menstruation is 
thoroughly and regularly established. 

EPILEPSY 

The clonic convulsions of epilepsy in a typical 
attack are sufficiently well-known] and require no 
renewed description here. The etiology of epilepsy is 
unknown. There exist one class in whom the seizures 
are definitely related to certain traumatic lesions of 
the skull, brain or meninges, or to some actually 
demonstrable lesion in the brain. This type of case may 
often be relieved by operative methods. Another type 
of epilepsy seems definitely associated with intoxica- 
tion. Of this theory there are many adherents. In 
fact, C. A. L. Reed has stated: "1. Epilepsy is caused 
by a specific infection, probably a bacillus of the gas- 
forming series. 2. The infection is located in the 
intestinal canal, probably primarily in the duodenum, 
always finally in the colon, and may be superficial, 
intrafollicular or interstitial, or may, and in certain 
cases probably does, involve the blood as a propagating 
medium. 3. The infection seems to be made effective 



378 TREATMENT OF EPILEPSY 

primarily through constipation of mechanical origin. 
4. The relief of the mechanical cause of the constipa- 
tion with restoration of bowel function results in the 
cure of epilepsy in cases in which the infection is 
probably superficial. 5. The principle of immunization 
holds good in the treatment of cases in which the 
infection obviously lies deeper, in all of which 
autogenous vaccination may well be applied as a mat- 
ter of routine." 

Gowers and others have stated distinctly that often 
there may be a hereditary tendency to epilepsy. Still 
other observers are convinced that a state of alco- 
holism, lead poisoning, or other poisoning in either 
parent at the time of impregnation may be a cause of 
epilepsy. Turner has defined as idiopathic epilepsy 
"a chronic disease of the brain characterized by the 
recurrence of seizures in which interference with 
consciousness is an essential feature, associated either 
with convulsions or transient psychical phenomena, 
occurring usually in persons with an hereditary neuro- 
pathic endowment and eventually leading to more or 
less permanent mental impairment and dementia. " 

TREATMENT 

If the patient is in the midst of an attack measures 
should be instituted to prevent him from being injured 
by the movements which accompany the convulsion. 
It is important that chewing of the tongue between the 
teeth be prevented. If immediately after an attack 
the physician be consulted the patient should be per- 
mitted to rest and recuperate before any active steps 
are taken to secure a history or to institute treatment. 

If the case be of that type in which it is likely 
operative treatment will be of benefit, the course is 
clear. 

In view of the possibilities outlined by Reed it 
certainly may be worth while to make an analysis of 
the gastro-intestinal tract and to make a bacteriologic 
study of the flora leading to the preparation of an 
autogenous vaccine. 

In those cases in which one fit succeeds another in 
rapid order and the possibility exists of a complete 



GENERAL TREATMENT OF EPILEPSY 379 

loss of consciousness, passing into a coma which 
presages the death of the patient, the immediate 
administration of a large dose of chloral or bromids, 
or both, may be considered. As much as 20 grains 
of sodium bromid with 10 grains of chloral hydrate 
every two to three hours have been given with suc- 
cess. The following mixture has been recommended : 

gm. or c.c. 

fy Chlorali hydrati 5| 3 iss 

Sodii bromidi 10 1 or 3 ii i 

Elixiris aromatici 50| flB ii 

Aquam ad 100| A3 iv 

M. et Sig. : As the physician directs. 

[Each teaspoonful of the above, i. e., 5 c.c, represents 0.50 
gram (7 J / 2 grains) of bromid and 0.25 gram (4 grains) of 
chloral.] 

In more serious forms it may be necessary to 
employ hypodermic injections of morphin or even 
chloroform inhalation to stop and prevent these ter- 
rific seizures. 

GENERAL TREATMENT 

The care of the epileptic patient should be organized 
to overcome so far as possible the source of his intoxi- 
cation and to reduce the hyperirritability. The patient 
should have an outdoor occupation if possible, or in 
any event some work in which he is not too closely 
confined. If not adapted for outdoor work of a 
strenuous character, the occupation should be light. 
If the epileptic cannot work he should have light 
systematic outdoor exercise. Plenty of sleep should 
be insisted on. The patient should bathe frequently 
and the value of strengthening and sedative hydro- 
therapeutic methods should not be overlooked. The 
diet should be ordered with care to exclude coffee, tea, 
alcohol and other cerebral stimulants. A regular con- 
dition of the bowels may be obtained by insistence on 
the use of fresh vegetables and fruits and the omis- 
sion of highly seasoned dishes and fat, greasy mix- 
tures. The amount of the food taken should be in 
proportion to the patient's capacity to assimilate with 
difficulty. In general a purin free diet has been advo- 
cated and it may be best to omit meats from the 



380 MEDICINAL TREATMENT OF EPILEPSY 

dietary and perhaps decrease in amount all fish, peas, 
beans, etc. 

If intestinal fermentation exists the use of lactic 
acid bacilli, either as buttermilk or in commercial 
preparations may be of aid ill checking it. The simul- 
taneous administration of sugar either as . such, or 
in the form of sweet fruits, syrups, or other prepara- 
tions, is of aid in achieving the desired result. 

MEDICINAL TREATMENT 

If the patient has an aura preceding his attack, he 
may be provided with pearls of amyl nitrite as it has 
been found in some instances the attack may be 
aborted by the inhalation of this substance. 

As constipation and intestinal intoxication seem to 
be important factors in the course of this disease, laxa- 
tives should be used as indicated by the patient's 
condition. 

Since Laycock, more than fifty years ago, introduced 
the bromid treatment of epilepsy, no other drug has 
been found more efficient in controlling the seizures. 
A daily dose of from 45 to 90 grains of the sodium 
salt is probably adequate. It has been shown that if 
the sodium chlorid of the food is reduced, a smaller 
amount of the bromid salt is required. The bromid 
treatment should be continued over several years if 
it seems efficacious and even beyond that, although 
no fits occur, in order to prevent the return of the 
symptoms. The bromid should not be withdrawn at 
once, but in decreasing dosage. 

Flechsig has advised a combined opium-bromid 
treatment which has given good results in his own 
cases as well as in those of other physicians. Kellner 
(Munch, mcd. Wchnschr., April, 1915) describes the 
method as follows : The opium is given three times 
daily for fifty days, beginning with 0.05 gm. of the 
extract of opium at a dose and increasing to a maxi- 
mum of 0.29 gm. The fifty-first day the opium is 
stopped and bromids are given. The dosage here must 
be cautiously individualized and supervised, watching 
for signs of intolerance or bromism and slowly reduc- 
ing the dose if such appear. Sudden suspension of 



HEADACHES 



381 



the bromids almost inevitably brings back the seizures. 
His usual dose of the bromid mixture for a strong 
adult is 5 gm. a day : 1 gm. in the morning and 2 at 
noon and again at evening. This is increased to 6 
gm. in a week and to 7 gm. after another week. He 
never goes above this latter dose, but thinks the 
bromids to be taken all the rest of the life if the 
epilepsy has been cured by this course of treatment. 
Prolonged observation has shown that a certain dose 
can be taken indefinitely without harm. 

Crotalin, a protein found in the venom of rattle- 
snakes, has been exploited as a cure for epilepsy. In 
general, experience seems to show that it is ineffective 
in relieving the disease, and Anderson, as well as many 
others, have shown that it may be exceedingly 
dangerous. 

Strontium bromid has been highly lauded by some 
as being superior to sodium or potassium bromid in 
the treatment of epilepsy. Such observations do not 
seem, however, to be borne out by either adequate 
clinical or experimental evidence. 

HEADACHES 
The causes of headaches have been divided by 
Osborne into several large classes : toxic, circulatory, 
local and reflex. 



TOXIC 


LOCAL 


Fever 


Eye inflammations 


Auto-intoxication 


Frontal sinusitis 


Intestinal 


E;hmoiditis 


Kidney insufficiency 


^ar inflammations 


Liver insufficiency 


Meningitis 


Thyroid disturbance 


Exudates into the ventricles 


Drugs 


Changes in the cerebral 


CIRCULATORY 


vessels. 


Valvular disease 


Tumors 


Venous congestion 


Syphilis 


Plethora 


REFLEX 


High tension 


Eye-strain 


Arteriosclerosis 


Nasal disturbances 


Anemia 


Aural disturbances 


Leukemia 


Facial neuralgias 


Lung consolidation 


Ulcrine displacements (?) 


Diminished aeration 





Campbell (Abst, Jour. A. M. A., Oct. 31, 1914, 
p. 1610) believes that the following classification will 



382 EYE-STRAIN HEADACHES 

be found a very convenient one for practical purposes : 
1. Organic disease of the cephalic structures — for 
example, meningitis, "rheumatic" effusion into the 
scalp. 2. External irritation of the cephalic struc- 
tures — for example, pediculi, traction on the hair. 
3. Irritation in areas other than the cephalic — for 
example, eye-strain. 4. Circulatory disturbances in 
the cephalic structures, and morbid states of the 
blood, causing functional headache. 5. Causes not 
included under the previous headings — for example, 
mental causes, physical exercise, atmospheric condi- 
tions. 

In the first three classes mentioned by Osborne, any- 
thing that removes or corrects the serious underlying 
condition will remove the headache of which the patient 
complains. It is in the fourth class, Osborne believes, 
that a failure of diagnosis of the cause is most fre- 
quently made, and it is this class that constitutes about 
90 per cent, of all cases of headache that come to the 
physician. It is his belief also that 90 per cent, of this 
fourth class suffer from headache because of some 
ocular trouble. 

EYE-STRAIN REFLEXES 

The most constant condition caused by eye-strain is, 
of course, the headache. This headache may develop 
slowly or rapidly, may be centered in one eye, one side 
of the forehead or one side of the head, or may be 
referred to both eyes. In fact, there is no part of the 
head that may not ache frome eye-strain. Very fre- 
quently, however, one eye is more likely to be affected 
than the other, as one eye is likely to be unlike the 
other eye and be more defective than the other eye. 
Astigmatism and far-sightedness, or both, are the most 
frequent causes of eye-strain headache. Weakness of 
the ocular muscles is another cause. 

The pain is perhaps most frequent in the supra- 
orbital region, but is often in the temple, and may be 
frequently referred to the inner angle of the eye, espe- 
cially if there is astigmatism. It perhaps occurs very 
frequently in this region on account of the overactivity 
of the superior oblique muscle which endeavors to 
overcome an astigmatic affection. Headaches from 
defective vision from any reason, and especially when 



EYE-STRAIX HEADACHES 383 

a person becomes presbyopic and has not glasses to 
correct it, or at least has glasses that are insufficient 
to correct it, are more likely to be in the occipital 
region. Such headaches most frequently occur in the 
early morning, and are discovered by the patient on 
awaking. 

Eyes that are defective as ocular instruments are 
likely to be inherited, certain kinds of eyes appearing 
in different members of the family, the children suffer- 
ing the same defect from which the parents suffered. 
Such children are likely to have the headaches begin 
at any age, but perhaps most frequently after a year 
or more of school work. These headaches are likely 
to come periodically, perhaps once a week, perhaps 
once in two weeks, perhaps only once a month, but 
with a constant tendency to become more frequent little 
by little. They sooner or later become a megrim, or 
migraine, which is typically a headache for a number 
of hours followed by nausea, vomiting, prostration, 
sleep, and recovery. 

The title given to most of these headaches by the 
laity is "a bilious attack," and the cause is attributed 
to overeating, eating at night, eating indiscriminately, 
or is attributed to particular kinds of food, which, if 
the patient is old enough to decide for himself, are 
gradually removed from the diet, until almost every 
kind of food and drink is subjected to more or less 
suspicion. He then attributes his trouble to his liver, 
or finds serious fault with his stomach. If he is con- 
stipated, he lays it to that, as he finds that after free 
catharsis, or at least after such a length of time as 
a cathartic will generally act, the headache disappears. 
He, therefore, thinks it is due to constipation. Girls 
and women with these eye defects are more likely to 
have headache before or during menstruation, and they 
attribute it to that function. Others learn that they 
get these headaches when they are overtired mentally 
or physically. Some soon learn to become suspicious 
of their eyes on account of having the headache after 
theater-going, card-playing, car-riding, shopping, sew- 
ing, or reading too long, or, if they are office clerks, 
after an extra amount of proof-reading or of mathe- 
matical work. 



384 TREATMENT OF HEADACHES 

After the headache habit has once been formed a 
neurotic element enters into it, and there is likely to 
be a clyclical headache, even if the eye defect has been 
corrected, so that a patient who has the headache 
habit thoroughly formed will always have them more 
or less, at least until the eyes become presbyopic and 
focusing for near objects has almost been abolished. 
It is also true that neurotic patients who are subject 
to high tension and nervous irritabilities are more 
likely to have headaches from slight eye defects than 
are more calm and less nervous individuals. 

All physicians now more or less recognize recurrent 
headaches as due to eye-strain, but a large number do 
not recognize that the patient may have stomach and 
heart reflexes without headache, and still due to eye 
defect. Dizziness, gastric indigestion, even nausea and 
vomiting may occur without any headache whatever 
and still be due to eye-strain. Cold hands and feet, 
chilly sensations, faint feelings, palpitation, and 
irregular heart and pain referred to the cardiac region 
so as to cause the patient to believe he has heart dis- 
ease, may be due to eye-strain and be corrected by 
correcting the eye defect. 

TREATMENT 

Patients with migraine are prone to become early 
victims of the nostrum promoter. The headache cures 
are as varied if not more so than the causes of this 
symptom. Practically all of them contain drugs of 
great toxicity or else consist of worthless mixtures 
with no appreciable effect. Recently acetylsalicylic 
acid (aspirin) has become the mainstay of the large 
group of laity who purchase headache "cures" in pref- 
erence to consulting a physician that he may aid in 
finding the fundamental reason for their pain. 

Tn all cases of migraine, Campbell says, treatment 
should consist of first a sufficiency of outdoor recrea- 
tive exercise, first strengthening the muscles, if 
required, and stimulating the patient's interest and 
pride in physical accomplishments ; second, a diet abun- 
dantly rich is cellulose with agar-agar added if neces- 
sary, and from which sugar is eliminated, protein given 
very sparingly and starch in moderation only ; third, 



EYE-STRAIN HEADACHES 385 

when the above diet and abundant diluents fail to keep 
the bowels free, the rectum should be attended to, or. 
this failing of effect, a saline as above advised should 
be regularly employed, and finally the patients should 
receive three times daily, after meals, a dose of spirits 
of glonoin sufficient for him to feel the physiologic 
effect in slight headache or throbbing of head or flush- 
ing of face shortly after taking each dose, and the dose 
should be maintained at or slightly beneath this. 
Remember that to maintain this effect, the dose has 
often to be greatly increased, sometimes to 30 drops 
or more three times a day. Such a regimen has, in 
Campbell's hands, brought much relief to patients with 
a condition in which the suffering headache, severe 
though it often be, is of minor importance compared 
to the effect on the cardiovascular system and life 
expectancy itself. 

Of those headaches due to ocular and reflex condi- 
tions, Osborne believes that nothing is more helpful 
than acetanilid. The dose should not be large and 
it is well to combine the drug with bicarbonate of 
sodium. While caffein adds to the toxicity of the 
coal-tar product, caffein has a useful action in curing a 
headache of the eye-strain class. If much of a dose 
of a coal-tar product is given, the patient should lie 
down for several hours, if possible. Otherwise, the 
cardiac depression caused by the eye reflex plus the 
depression caused by the coal-tar drug will produce 
faintness and more or less temporary debility. While 
acetphenetidinum (phenacetin) is perhaps a safer coal- 
tar drug to use, the dose must be so much larger than 
the acetanilid dose that the depression is about the 
same. With some patients antipyrin works the best. 
With other patients a brisk catharsis is advisable. 
Some find cold to the head of advantage, although with 
many it causes nausea. Others find hot applications 
satisfactory. Sometimes a hot foot-bath will change 
the circulation sufficiently to relieve the head conges- 
tion. Some patients are cold, and some feel hot, and 
the circulation on the surface of the body is likely to 
vary depending on the intensity of the pain or the 
occurrence of nausea. 



386 PRESCRIPTIONS FOR HEADACHE 

Opium treatment for these headaches is undesir- 
able. On the other hand, one is often driven by the 
very intensity of the condition to the limit of medicinal 
resources, and sometimes cardiac depression is so 
serious that it becomes a question of either morphin 
or large doses of alcohol. Patients who have these 
terrible megrim attacks frequently cannot well stand 
coal-tar products so often repeated, as, unless the dose 
is enormous, the result of their administration is nil. 
A morphin habit and an alcohol habit, to say nothing 
of the frequent acetanilid habit or caffein habit, may 
be acquired on account of eye-strain headaches. 

It is hardly necessary to mention the reflex head 
pain that may come from a bad tooth, from an inflam- 
mation in the antrum of Highmore or the frontal sinus, 
or from inflammations in the ear, as these diagnoses 
of causes of headache should be readily excluded. 

It should be remembered that frontal headache is 
frequently caused by syphilis. 

It should also be remembered, if there is insufficient 
pulmonary ability, whether from tuberculosis, emphy- 
sema, pleurisy with effusion, or asthma, that this lack 
of proper aeration may cause headache. 

At times gastric hyperacidity and uterine displace- 
ments may be reflex causes of headache, but such 
causes are rare. 

The wearing of heavy hats and heavy masses of hair 
may be the cause of headaches in girls and young 
women, to say nothing of the pernicious spotted veil. 



FOR HEADACHE 

gm. 
R Caffeinae citratae 2 3 ss 

Sodii bromidi 20 or 3 v 

Sodii bicarbonatis 10 

Acidi tartarici aa 10 3 iiss 

M. et fac chartulas 10. 

Sig. : One powder in half a glass of water, and repeated 
in six hours, if needed. 

[In order that these powders may effervesce well they must 
be kept dry.] 



PRESCRIPTIONS FOR HEADACHE 387 

Or: 

gm. 

R Acetanilidi 150 gr. viiss 

Caffeinae citratae |25 or gr. iv 

Sodii bicarbonatis 5| 

Acidi tartarici aa 5| gr. lxxv 

M. et fac chartulas 5. 

Sig. : One powder, in half a glass of water, every three 
hours, if needed. 

[In order for these powders to effervesce well they must be 
kept dry.] 

Or: 

gm. 
Ifc Acetphenetidini 1 50 gr. xxiiss 

Caffeinae citratae 25 or gr. iv 

Sodii bicarbonatis 5 

Acidi tartarici aa 5 gr. lxxv 

M. et fac chartulas 5. 

Sig. : One powder, in half a glass of water, every three 
hours, if needed. 

[In order for these powders to effervesce well they must be 
kept dry.] 

Or: 

gm. 
fy Pulveris potassii bromidi effer- 

vescentis (N. F.) 100| or 3 iii 

Sig. : A heaped teaspoonful, in a glass of water, when 
needed. 

[Each such teaspoonful represents 0.60 (10 grains) of 
potassium bromid.] 

Or: 

gm. 
fy Pulveris potassii bromidi effer- 

vercentis cum caffeina (N. F.)..100| or 5 iii 

Sig. : A heaped teaspoonful, in a glass of water, when 
needed. 

[Each such teaspoonful represents 0.60 gram (10 grains) of 
potassium bromid and 0.065 gram (1 grain) of caffein.] 

A STIMULANT IN CEREBRAL DEPRESSION 

gm. or c.c. 
R Caffeinae sodio-benzoatis (N. F.) 4| or Si 
Aquae menthae piperitae 100] 3 iii 

M. Sig. : A teaspoonful, in water, every four hours, if 
needed. 

[Caffein sodio-benzoate consists of equal parts of caffein 
and sodium benzoate.] 



388 SCIATICA 

Or, to effervesce : 

gm. 

ty Caffeinae sodio-benzoatis (N. F.) 2| 3 ss 

Sodii bicarbonatis 10| or 

Acidi tartarici aa 10 1 3 iiss 

M. et fac chartulas 10. 

Sig. : One powder, in half a glass of water, every four 
hours, if needed. 

SCIATICA 

The sciatic nerve is one of the frequent locations of 
nerve pain, and is perhaps more frequently the loca- 
tion of a neuritis or a perineuritis than any other nerve 
of the body. All possible causes of the condition must 
be sought for and found or excluded, and before a 
general condition, or a condition of the blood, is 
decided to be the cause of the neuralgia or inflamma- 
tion, all local reasons should be excluded. 

A frequent cause of sciatica in women is pressure 
on the nerve in the pelvis, either from uterine displace- 
ments, uterine enlargements, tumors or inflammation 
that has extended and caused pressure. 

Constipation, with fecal matter remaining long in 
the lower bowel, is also a not infrequent cause of 
sciatica, and such a condition of the loaded sigmoid 
is a not uncommon cause of left-sided sciatic pain. 

Gout and rheumatism certainly are many times the 
cause of sciatic neuritis. 

Exposure to wet and cold, especially when the feet 
become wet and chilled, or sitting on cold stones, or 
long sitting on hard-bottomed chairs, may be the initial 
cause of a sciatic neuritis. 

Pain in the lumbar muscles, lumbago or lumbar 
myalgia, is often followed by pain in one or the other, 
or both sciatic nerves ; or both conditions may be pres- 
ent at once. In fact, frequently when there is no evi- 
dent abdominal or pelvic excuse, a lumbago is followed 
by pain in a sciatic nerve. A not infrequent cause of 
a lumbago is too lax springs and a too comfortable 
bed. This is especially true when the person is of 
heavy weight A stiffening of the bed springs and a 
straightening of the bed will often be sufficient alone 
to stop this kind of pain which is so frequent, and also 
so frequently extends to the sciatic nerves. 



TREATMENT OF SCIATICA 389 

A weakening of the plantar arch and an attempt of 
the person involuntarily so to step and stand as to 
relieve the ache in the ankles and feet will cause 
abnormal muscle tension, even of the thighs,* and a 
sciatic pain can be caused from this reason, to say 
nothing of the frequent pain in the knees from this 
cause. 

Uricacidemia, and even an increased acidity of the 
urine, with bladder irritability, is often a concomitant 
condition w T ith sciatica. The sluggish circulation due 
to an imperfect heart action or to a varicose condition 
of the leg may be a predisposing cause of sciatic pain. 
It is hardly necessary to mention the occasional causes 
of sciatica, as diabetes, malaria, syphilis and hip-joint 
or knee-joint disease. 

Often in cases of sciatica foci of infection else- 
where in the body may be found to bear some relation- 
ship to . the cause of the sciatica. Carious teeth, 
infected tonsils, or other foci when present should 
be removed. The result may be a complete and perma- 
nent disappearance of the sciatic pain. 

TREATMENT IN GENERAL 

Consequently, before beginning any local or general 
treatment for sciatica, the patient should be carefully 
examined and any local cause found, the circulation 
investigated, the urine analyzed, and the intestinal 
digestion and activity learned. It should also be deter- 
mined whether the pain is due to neuralgia, i. e., a 
simple irritation of the sciatic nerve, or whether there 
is an actual neuritis or perineuritis, which may be 
determined by excessive tenderness, pain on stretch- 
ing the nerve (as by thoroughly extending the leg) 
or by a beginning anesthesia in any part of the dis- 
tribution of the nerve. 

It is not necessary to urge the necessity for remov- 
ing local pressure, if such has been found, before it 
could be expected that the sciatica or the neuritis could 
be made better. Free elimination from a calomel, cas- 
tor oil, or saline purgative, and subsequent daily free 
movements of the bowels is certainly a large factor in 
the successful treatment of sciatic trouble. The char- 
acter of the diet should be determined by the condition 



390 TREATMENT OF SCIATICA 

of the patient. If the patient needs nutrition, the most 
nutritive diet possible should be given, and, in fact, 
perhaps hyperalimentation given. On the other hand, 
if the patient is plethoric, has been a high liver, eating 
largely of proteids, especially meats, a vegetable and 
limited diet for a time, at least, is the best. If the cir- 
culation is impaired, it should be aided. If the cir- 
culation is good, plenty of water should be given to 
aid the eliminative process by the kidneys. Hot daily 
tub baths, a Turkish bath twice a week, or a body 
hot-air treatment twice a week, are all adjuvants in 
the treatment of sciatic inflammation that are far 
ahead of medicinal treatments. The body hot-air 
treatment is most efficacious when rheumatism is the 
cause of the condition, and no treatment is perhaps 
more successful. This is also especially true when 
there is kidney insufficiency. The promotion of the 
circulation in the skin and the increase of the excre- 
tory ability of the skin is a large factor in the benefit 
derived from such treatment. 

Occasionally the attack of sciatica comes on sud- 
denly, but generally it is gradual in its development, 
and the longer it has persisted the more difficult it is 
to cure ; consequently, sciatica, even in mild form, 
should not be neglected. 

It is probable that the shooting pains down the sci- 
atic nerve, momentary perhaps in their duration, are 
caused by contractions of the pyriformis muscle, which 
compresses the sciatic nerve. It is also probable that 
this muscle sometimes becomes irritated and inflamed 
and keeps up, by its contractions, pressure on the sci- 
atic nerve. If such pressure is more or less continuous, 
sciatic neuritis could be caused. This condition being 
surmised or suspected, local treatments aimed at 
relieving the spasm of this muscle should be instituted. 
Among such measures may be included static wave 
currents, mechanical vibration and sparks from a 
static machine locally applied to the region of the 
foramen through which the sciatic nerve leaves the 
pelvis. Also sometimes beneficial is the application 
of dry heat to this part, and perhaps best by the 
reflected heat and light of a strong electric light. 



XERVE-STRETCHING 391 

Sometimes counter-irritation along the course of the 
sciatic nerve by momentary localized applications of 
the galvanic electric current with the positive pole 
active, or painting along the course of the nerve with 
iodin, or electric light bath treatment to the whole 
course of the nerve, or dry cupping along the course 
of the nerve and repeated on successive days, will 
abort a beginning neuritis. In an ordinary case of 
sciatic neuralgia, if the cause is removed, the neuralgia 
will cease. 

If beginning neuritis or perineuritis is suspected 
or diagnosed, absolute rest of the limb on a level, 
hard bed, with electric light applications or dry heat 
applications, with the administration of alkalies or 
salicylate, and the general management of the bowels 
above outlined, may still abort the inflammation. 

If, on the other hand, an actual neuritis is present, 
there is. nothing that will shorten an attack so much 
as a long splint from the axilla to the heel, to give 
permanent fixation and rest. If a splint is used for 
this purpose, the bandage which binds it should be 
removed at least once, and perhaps better twice, a day 
and the limb gently flexed once or twice so that the 
joints will not become stiffened. The length of time 
such a splint should be used is determined by the 
amount of pain and the rapidity with w r hich the 
inflammation improves. No fixed rule can be estab- 
lished. Another method of fixing and treating a limb 
so affected is by long sand bags, which may be put 
into the oven and rendered very hot,, and changed as 
often as they become cool. Such applications give 
rest to the limb and constant dry heat. If such heat 
is not applied, the limb should be swathed in cotton 
and bandages, as warmth is very essential in all cases 
of neuritis. 

STRETCHING THE NERVE 

Stretching of the nerve by operative measures has 
been advocated by Nannini (Reforma Medica, 1914, 
xxx, p. 813). Nannini reports a cure by this means 
in six cases of chronic sciatica which had long resisted 
all other measures. The cure was prompt and per- 
manent and he marvels that practitioners in general 
do not resort oftener to this comparatively simple 



392 NERVE-BLOCKING 

procedure. The nerve must be reached by pushing 
the muscles out of the way, through an incision in 
the rear of the root of the thigh, just below the edge 
of the buttocks. The nerve must be freed from adhe- 
sions and isolated over a certain stretch and then 
the peripheral and the central ends pulled in turn, 
gently and continuously, without sudden jerks liable 
to injure the nerve. The traction should be applied 
under general anesthesia and in such a way that the 
mechanical effect can be felt the entire length of the 
nerve. The effect is enhanced by having the limb 
flexed and then stretched to the utmost by an assistant 
as the traction is being applied several times. There 
are vague pains at first for a few days and then pares- 
thesia in the lower leg, possibly a sensation as if the 
leg were gone; then all symptoms fade away and by 
the tenth or twelfth day the patient can get up and 
begin to use his leg. 

NERVE BLOCKING 

Injections into the sheath of the nerve, so-called 
"nerve blocking/' of various solutions has been found 
in some instances to be an extremely efficacious 
measure. Sometimes the injection of cold water or 
of a small dose of cocain directly into the nerve sheath 
in the region of the sciatic notch will cause almost 
instant cessation of the pain. Alcohol too has been 
used for this purpose. In general the use of drugs 
for this purpose may result in harm and should per- 
haps be attempted only as a sort of last resort. Lethaus 
(Deut. med. Wchnschr., 1914, xl, No. 38) injects 
100 c.c. of a 1 per thousand solution of a mild anes- 
thetic at the point where the sciatic nerve emerges 
from the great sciatic foramen, between the trochanter 
and the tuberosity of the ischium. The injection is 
made into the nerve itself when possible, but often 
it is merely a perineural injection. It is repeated after 
an interval of eight days ; sometimes three or four 
injections are necessary to realize a complete cure. 
No untoward by-effects were observed in any instance 
in his experience. When repeated injections do not 
accomplish the purpose, he tries epidural injections, 
and has sometimes had good results. For this he 



VACCIXES TX SCIATICA 353 

injects 10 or 20 c.c. of salt solution into the epidural 
sac through the sacral hiatus, the patient in the knee- 
elbow position. Sometimes three or four injections 
had to be made to cure the sciatica completely. In 
some cases both these measures failed, and recurrence 
was sometimes observed. This is not to be wondered 
at, he says, as persons subject to sciatica are usually 
those with a predisposition to nerve and joint derange- 
ment. He warns that no attempt should be made to 
block the nerve when the sciatica is the result of some 
general disease, such as malaria, influenza, nephritis, 
diabetes, arteriosclerosis, or lead or alcohol poisoning, 
also the pains liable to occur in the hysteric and neu- 
rasthenic which masquerade as sciatica but are really 
of central origin. Oppenheim's "psychalgias" are like- 
wise not suitable subjects for nerve blocking. But 
when the above can be excluded, Lethaus advocates 
prompt resort to injection treatment in chronic sciatica 
rebellious to other measures. He does not wait longer 
than from four to six weeks, during which time bed 
rest, sweat baths, packs of the limb affected, diather- 
mia and the usual antineuralgic and antirheumatic 
measures are systematically applied. 

VACCINE TREATMENT 

The vaccine treatment of sciatica, according to 
Zappfe (Jour. A. M. A., Jan. 16, 1915, p. 238), has not 
received the attention it deserves. Little is said about 
it in text-books, and only gonococcus vaccine is men- 
tioned. Greeley cites one case treated successfully 
with vaccine made from a throat coccus. He gave only 
three injections — 100 million, 200 million and 400 
million, respectively, with a final precautionary dose 
of 800 million. These cases, Zappfe believes, open up 
a wide field for vaccine therapy, but in order to follow 
it out intelligently one must be versed in the whole sub- 
ject of vaccine therapy. The cases must be selected 
carefully and the treatment must be given with good 
judgment. The source of infection, that is, the infec- 
tion focus, must be determined, and usually can be 
found by patient, persistent search. It may be elusive, 
but it exists. And when found, a vaccine is easily 
obtained. Cases not amenable to vaccine therapy will 



394 .MEDICINAL TREATMENT OF SCIATICA 

yield negative results ; therefore, every other possible 
source of the sciatic pain should be investigated thor- 
oughly before vaccine therapy is tried, and then the 
same principles which make for success in this form 
of treatment in general hold good here. 

MEDICINAL TREATMENT 

When the pain is intense, and especially if periodi- 
cal contractions of the muscles occur (which, how- 
ever, are best prevented by the long splint), injections 
of morphin must be given. But perhaps nothing will 
prevent the necessity of such injections more than the 
ability to give the leg perhaps, but better the whole 
body, hot-air treatment, which, of course, can only 
be done well in an institution. The amount of mor- 
phin that is needed and the frequency depends on the 
pain. Such frightful pain cannot be endured, and, if 
not stopped by other means, must be stopped by 
morphin. 

The coal-tar analgesics are only of temporary benefit 
in mild cases, are never of benefit when there is severe 
pain, and, as the need for an analgesic is so frequent 
in sciatic neuritis, great debility would be caused by 
such repeated use of them. Ordinarily, therefore, they 
should not be used in sciatic neuritis. 

There is no really good reason for using atropin 
hypodermatically in sciatic neuritis. The pain of neu- 
ritis comes from the main trunk of the nerve and is 
distributed more or less to all its branches. Atropin 
only dulls nerve pain when that pain is due to periph- 
eral irritation. If atropin is used in conjunction with 
morphin it does nothing but inhibit the narcotic and 
quieting effects of the morphin, and more morphin is 
required. Also, if the dose of morphin must be 
repeated for severe pain, the discomfort of the patient 
is increased, the restlessness is increased, and the 
secretions are decreased by the frequent repetition of 
atropin. 

It should he understood thai a sciatic neuritis is like 
any other neuritis, and, therefore, will first grow 
worse, reach its aenie, and then gradually and slowly 
become better, with anesthesias, pain, and more or less 
paralysis. The patient should be told that a long, 



BACKACHE 395 

tedious process is before him, and that no exact time 
limit to the duration of the inflammation can be 
promised. 

After the acute condition is past, massage, possibly 
gentle counter-irritation, faradic stimulation of the 
muscles, or other electric or hydrotherapeutic mea- 
sures may be used to bring the leg back to normal 
function. 

It should be again emphasized that probably the most 
efficient means of shortening the inflammation in the 
nerve and hastening recovery is by the hot-air treat- 
ment. 

BACKACHE 

Under this heading Lovett {Jour. A. M. A., 1914, 
lxii, p. 1615) has included the various aches and lame- 
nesses which are popularly attributed to kidney or 
uterine disease. The picture of an individual with his 
hand pressing on that portion of the back beneath 
which the kidneys are supposed to lie — by the laity 
— and the familiar caption "Does Your Back Ache ?" 
is recognizable as the chief advertising slogan of a 
number of nostrums issued for use in kidney distur- 
bances. In medical literature backache has been 
described under any of the following headings : neu- 
rasthenic spine, hysteric, irritable or railroad spine, 
chronic lumbago, uterine backache, static backache, 
relaxation of the sacro-iliac joint, sacro-iliac strain, 
rheumatism of the spine, chronic back-strain, etc. 
Spinal tuberculosis, organic nervous disease and the 
effects of spinal fracture are excluded from this con- 
sideration. The most important symptoms are : insis- 
tent or intermittent dragging pain in the lower part of 
the back, sometimes one-sided and sometimes bilateral, 
generally aggravated by standing or walking and often 
shooting down into the buttock and backs of the 
thighs. Lameness in bending may be present and 
tenderness is usually found over the lumbar region 
and region of the sacro-iliac joints. The patients 
usually like to have the small of the back supported 
by a cushion. Coccygodynia is not unusual. The affec- 
tion may come on gradually or suddenly ; it is more 
common in women than in men and in certain types 
of figure such as the kangaroo and gorilla types of 



396 CAUSES OF BACKACHE 

Dickens and Foster, the overfeminine type of Reynolds 
and cases with slight lateral curvature. The resistance 
of the patients is usually less than the average and the 
disorder is notoriously chronic. The symptoms may 
be slight, or severe enough to make the patient a 
chronic invalid. Lovett gives the fundamental ana- 
tomic facts that bear on the condition and enumerates 
three etiologic classes : ( 1 ) those from disease or dis- 
placement of the pelvic organs; (2) those due to 
traumatism; (3) those from arthritis of the spine. 
There are many mixed cases, however, and there is 
still an unclassified group for which two theories have 
been offered and which he proceeds to discuss : ( 1 ) the 
theory of static origin which has been advocated by 
himself and Reynolds; (2) those due to sacro-iliac 
strain or relaxation. The former of these he prac- 
tically .accepts ; the sacro-iliac theory is rejected by 
him. As regards the effects of strain, he considers it 
a more general attitudinal one than one affecting the 
sacro-iliac joints. The diagnosis of static backache 
means that the surgeon must look into the cause of 
it and try to remove it before treatment. Pelvic back- 
aches have some characteristics distinguishing them 
from those of static origin, and this favors the view 
that they are most often caused by the forward bent 
position, causing increased efforts on the part of the 
posterior muscies. Mixed cases are frequent. A 
puzzling class of cases lies between those associated 
with trauma and those clearly arthritic, but in many 
cases the latter diagnosis is not supported by the results 
of treatment. In many cases due to defective balance 
and Hat-foot, inequality of the limbs, etc., arc reported. 
Backache due to relaxed and slumped attitude is per- 
haps the most common type of static backache. In an 
analysis of eighty-three cases, twenty-nine males and 
fifty-four females, there were forty-one of static back- 
ache, the majority due to defects of anterior posterior 
balance; there were six pelvic cases, twenty traumatic 
and fifteen arthritic. There was one case attributed 
to acute lumbago. In cases from traumatism we ma} 
assume a sprain <>t the spinal joints or pelvis. If 
they are non-traumatic, defective balance may be 
sought for. In all cases o! women the possible pelvic 



BACKACHE DUE TO FLAT-FOOT 397 

cause must be borne in mind. The case must be 
classed as probably arthritic when it is chronic and 
there is marked stiffness and pain on motion. Referred 
pains in the legs and disturbances of sensation are 
suggestive. Some cases can hardly be classed, how- 
ever, and a hysteric or neurasthenic spine is no diag- 
nosis at all. The prognosis depends largely on the 
possibility of removing the cause. In balance cases 
proper treatment should succeed unless the patient is 
neurasthenic. Pelvic cases should go to the gynecolo- 
gist, and the outlook for traumatic cases is favorable 
except in elderly persons or those undertaking litiga- 
tion. In arthritics the treatment consists in fixation 
of the spine, and he prefers a canvas lacing in the back 
with light steel straps to plaster-of-Paris casts. Defects 
of balance should be carefully studied, and a correct 
corset should be prescribed. 

Backache due to flat-foot, Graham (Old Dominion 
Jour. Med. and Surg., October, 1914) believes, usu- 
ally disappears promptly when the inner sides of the 
heels of the boots are elevated %. of an inch and the 
inner corners of the heels set J /> inch farther forward 
than the outer corners. If this does not afford the 
desired relief the arches may be supported by felt pads 
or steel supporters. Of the two forms of support 
mentioned, Graham much prefers the felt instep pads 
to the rigid steel supports. The most common surgical 
cause of continued backache met with in children and 
occasionally encountered in adults, he says, is spinal 
caries or tuberculosis of the spine. When acute, as 
evidenced by marked muscular spasm of the back and 
exquisite pain, the patient should be placed on a Brad- 
ford frame with a bag of sawdust underneath the 
spine so as to produce a posture of hyperextension. 
When the acute stage has sufficiently subsided a plaster 
corset is applied extending from the sternal notch 
above to a point just sufficient to allow the patient to 
sit down. During the later stage of convalescence a 
steel brace may be worn. When ankylosis is well 
established and all pain has disappeared all support 
may be gradually omitted. 

Sacro-iliac strain is relieved in the milder cases 
by adhesive strips which should be placed diagonally 



398 ADHESIVE STRAPPING IN BACKACHE 

across the lumbar region. Starting at a point just 
below the anterior superior spine, the strip of adhesive 
is carried diagonally across the back. Then one is 
started on the opposite side and carried across in a 
similar manner. The successive strips overlap each 
other from y$ to ]/ 2 of the width of the strip. Then 
circular bands encase the pelvis. For the chronic 
types of sacro-iliac strain a leather belt around the 
pelvis often affords perfect relief. This belt is worn 
tight around the pelvis in order to prevent movement 
in the sacro-iliac joint. In the more serious types 
fixation by plaster or a steel splint are indicated. For 
spondylitis deformans, a condition in which bony 
deposits are thrown out around the articular surfaces 
of the. vertebra and on the spinous and transverse 
processes, producing a painful and deforming condi- 
tion, a long plaster corset extending from the pelvis 
to the suprasternal notch offers the best hope of relief. 
Lumbago is best treated by the criscross adhesive 
strapping as described for sacro-iliac strain, except 
that it is not necessary in this condition to encircle 
the pelvis. Visceroptosis causes much backache which 
can be relieved by a corset which fits snugly around the 
pelvis and supports the abdominal viscera and strength- 
ens the abdominal wall. The corset should begin to 
be less snug as it leaves the brim of the pelvis, and 
should gradually become more open from that point 
u]) ward. In exceptional cases an abdominal pad or an 
abdominal supporter, to be worn inside the corset, is 
indicated. Static back, a condition indicated by weak, 
flabby muscles and accompanied by faulty weight bear- 
ing and pain, calls for massage, exercises and a prop- 
erly adjusted corset. Scorbutic spine is best treated by 
recumbency on a Bradford frame, with the spine 
hyperextehded, proper attention being given to diet 
and hygiene. 



INTOXICATIONS 



THE TREATMENT OF DRUG ADDICTIONS 

The Harrison antinarcotic law, which became effec- 
tive March 1, 1915, deprived many addicts of their 
drug and caused considerable suffering. Numerous 
methods have been devised to wean patients from the 
drug habit. 

THE LAMBERT-TOWNS METHOD 

The Lambert (sometimes referred to as the Lambert- 
Towns) method of elimination and rapid withdrawal 
has proved quite satisfactory. This method has been 
described by Dr. Alexander Lambert in The Journal 
of the American Medical Association, and is here 
repeated. This must not be regarded as a cure for 
drug habits, but is intended to obliterate the terrible 
craving which these patients suffer when deprived of 
their accustomed drug. Vigorous elimination is the 
most important feature of the method, and is secured 
by the administration of compound cathartic pills and 
blue mass or some other form of mercury. The other 
essential measure is the persistent use of the following 
belladonna mixture : 

Gm. or c.c. 

I£ Tincturae belladonnae (15%) 62 

Fluidextracti xanthoxyli 

Fluidextracti hyoscami, aa. 31 

With these two prescriptions as a basis the following 
steps in the treatment are to be observed : 

A patient addicted to morphin is given five com- 
pound cathartic pills and 5 grains of blue mass. Six 
hours later, if the bowels have not moved, a saline is 
given. After three or four abundant movements of 
the bowels (and not until then) the patient is given 
by mouth or hypodermically, depending on his habitual 
method of taking the narcotic, in three divided doses, 
at half-hour intervals, two-thirds or three-fourths of 
the total daily twenty-four-hour dose of morphin or 
opium to which he has been accustomed. Observe the 



400 TREATMENT OF MORPHINISM 

patient closely after the second dose, when about half 
the total twenty-four-hour dose has been taken. A 
few patients cannot comfortably take more than this 
amount. Six drops of the belladonna mixture dropped 
with a medicine dropper are given in capsules at the 
same time as the morphin or opium, and should be 
repeated every hour for six hours. At the end of six 
hours the dose of the mixture is increased 2 drops. 
This dose is then continued at hour intervals for 
another six hours, when the dose is increased by 2 
drops, and again continued at the same interval, 
increasing the dose each six hours until it reaches 16 
drops. It is then continued in this amount, but is 
diminished or discontinued at any time if the patient 
shows belladonna symptoms such as dilated pupils, 
dry throat or redness of the skin, or mental symptoms. 
It is begun again at reduced dosage after these symp- 
toms have subsided. Unusual sensitiveness to bella- 
donna will usually be manifest in six or eight hours, 
when the dose can be cut down 2 to 4 drops and then 
raised by 1 drop every six hours. On the other hand, 
if after twelve hours the 16 drops have not produced 
dryness of the throat the dose may be increased to 
18 or 20 drops every hour until the dryness occurs, 
and then the amount may be reduced. 

At the tenth hour after the initial dose of morphin 
five compound cathartic pills and 5 grains of blue mass 
should again be given. If they have not acted in six 
or eight hours, give some vigorous saline. When the 
bowels have acted vigorously, which is usually at about 
the eighteenth hour, give half the original dose of 
morphin; that is, one-half or three-eighths of the 
original total daily dose. The belladonna mixture is 
still continued, and ten hours after the second dose of 
morphin, five compound cathartic pills and 5 grains of 
blue mass are again given, if necessary, followed by a 
saline seven or eight hours later. After the bowels 
have acted thoroughly, at about the thirty-sixth hour, 
the third dose of morphin is given, which should be 
one-sixth or three-sixteenths of the original dose. 
This is usually the last dose of morphin. Ten hours 
after the third dose of morphin, the forty-sixth hour, 
again give the five compound cathartic pills and 5 



TREATMENT OF MORPHINISM 401 

grains of blue mass, followed seven or eight hours 
later by a saline. After the bowels have moved thor- 
oughly a bilious green stool should be expected and 
after its appearance 2 ounces of castor oil should be 
given to clear out thoroughly the intestinal tract. It 
is sometimes found necessary to continue the bella- 
donna mixture over one or two additional cathartic 
periods before giving the oil. After giving the last 
dose of compound cathartic pills, and before giving 
the oil, the patients will have their most uncomfortable 
time, and may be relieved by 5 grains of codein hypo- 
dermically. This should not be kept up long after the 
oil is given. Beginning about the thirtieth hour the 
patient should be given strychnin or digitalis or both 
every four to six hours. 

Withdrawal pains can sometimes be relieved by 
ergot and strychnin, by massage, sodium salicylate or 
by some salicylic compound combined with coal tar 
products such as antipyrin, acetphenetidin or pyra- 
midon. Indiscretions in eating or exercise two or 
three days after stopping the drug may cause a recur- 
rence of the withdrawal pains, due to exhaustion or 
indigestion. This trouble will quickly disappear with 7 
out narcotics. 

Insomnia may be troublesome and may be treated by. 
bromids, cloral or other hypnotic. Lambert's experi- 
ence is that veronal acts badly in these cases. Muscu- 
lar fatigue is the best hypnotic, and regular exercise 
may be carefully taken within a week after the dis- 
continuance of the drug. It is important to build up 
the patients physically. 

Morphin and alcohol addicts should be treated for 
the morphin addiction and the alcohol may be tapered 
off gradually. The gastritis usually found may cause 
difficulty in retaining medicines or food. Sodium 
citrate in doses of 5 to 10 grains every hour will relieve 
this condition, and if necessary may be supplemented 
by 10 to 20 grains of cerium oxalate. 

Cocain and morphin addiction make a difficult com- 
bination to treat, but the procedure should be that 
for morphin, with plenty of strychnin or other stimu- 
lant. The cocain should be withdrawn at once. The 



402 PETTY TREATMENT OF MORPHINISM 

patients may become delirious and unmanageable after 
the effect of the morphin wears off. 

The cocainist should be treated like the alcoholic, by 
withdrawing the cocain, giving the belladonna mixture 
every hour, increasing as with the morphin patients, 
and the five compound cathartic pills and 5 grains of 
blue mass, the first doses being taken simultaneously. 
At the end of the twelfth hour repeat the cathartics 
and the saline, and likewise at the twenty-fourth and 
thirty-sixth hours. After the last cathartic the bilious 
stools will appear, and at the forty-fourth or forty- 
fifth hour the castor oil is given. Unless the bilious 
stools appear it may be necessary to continue the treat- 
ment over one or two more cathartic periods. 

Though each patient presents an individual problem, 
Lambert insists that the plan must be adhered to 
closely. The cholagogue action of the mercury is 
essential and the persistent repetition of the doses of 
the belladonna mixture so as to produce the physiologic 
effect is required to prevent the craving for the drug. 

pettey's method 

The method of Pettey in morphin addiction also 
employs active purgation as one of its principal fea- 
tures, with sedation in the form of scopolamin after 
the drug is withdrawn, with large doses of strychnin 
in the purgative to increase peristalsis and also after- 
ward for its supporting effect. The steps in the treat- 
ment may be described as follows : 

On the day the treatment is begun the patient may 
take his usual doses of the drug. He is required to 
abstain from dinner and supper, and at 4, 6, 8 and 10 
]). m., he is given the following purgative prescription 
divided into four capsules: 

R Calomel 

Powdered Extract Cascara Sagrada aa. . . gr. x 

[pecac gr. i 

Strychnin nitrate gr. V\ 

Atropin sulphate gr. 1 ,- 1 d 

No opiate and no nourishment are to be given the 
following morning until the bowels have moved thor- 
oughly. In order to insure the movement of the bow- 
els, six or eight hours after giving the last purgative 



PETTY TREATMENT OF MORPHINISM 403 

capsule, 1/20 grain of strychnin should be given hypo- 
dermically and a half hour later 2 ounces of castor oil 
or a bottle of citrate of magnesia. Both the strychnin 
and the oil or saline should be repeated every two 
hours until the intestinal canal has been thoroughly 
emptied, and no morphin should be given during this 
time. The thorough elimination will afford relief from 
the discomfort of abstinence from the drug and this 
should be taken advantage of to postpone the morning 
dose of the narcotic. When the demand for the drug 
becomes insistent it may be given in not more than one- 
half to two-thirds the usual dose at the same intervals 
at which the drug was formerly taken. After the 
purgation liberal feeding may be allowed until within 
six or eight hours before the next purgative course. 
This should be forty-eight hours from the beginning 
of the first purgative course, and may be more or less 
active, according to the effect obtained from the first, 
but none of the purgative ingredients should be left 
out, and large doses of strychnin are insisted on. The 
morphin in reduced dose, sufficient to keep the patient 
comfortable, may be continued until the last dose of 
the second purgative course, when the drug is to be dis- 
continued and no other opiate should be given. Six 
or eight hours after the second purgative course has 
been completed, strychnin hypodermically and the oil 
or saline should be repeated as after the first course, 
until free bowel movements occur. The patient will 
now be able to go longer before feeling the effect of 
abstinence from his morning dose, especially if he 
remains in bed, which he should do. Within six or 
eight hours after the time for the morning dose the 
patient's demand for relief from discomfort should 
be met by giving, instead of the opiate, 1/200 grain 
scopolamin hypodermically, and this should be repeated 
in thirty minutes. If the patient has not fallen asleep 
after the second dose a third may be given in a half 
hour or hour, which may be of the same size or double 
the previous dose, depending on the effect. This will 
produce either sleep or mild intoxication, in either of 
which conditions the patient will not suffer. Immedi- 
ately he awakes another dose of scopolamin, 1/200 
grain, should be given, and repeated to keep up a mild 



404 SCELETH TREATMENT OF MORPHINISM 

belladonna intoxication and to maintain the patient 
free from pain. This impression from the scopolamin 
should be kept up for thirty-six to forty-eight hours 
after beginning it, and then should be discontinued. 
During the scopolamin period and for twenty-four 
hours afterward, 20-grain doses of sodium hyposul- 
phite may be given every two hours, which will sup- 
plement the effect of the calomel purgative and the 
patient will have small, bilious stools, unattended by 
colic or griping. 

Convalescence will be reached on the fifth or sixth 
day and no further medication is indicated as far as 
the addiction is concerned and the patient will be 
comfortable. Deficient heart action during or after 
treatment may be treated by spartein sulphate in doses 
of 2 grains every four to six hours. 

Jennings' treatment 

The treatment of Oscar Jennings consists in giving 
dionin in place of the morphin, accompanied by spar- 
tein sulphate, the doses of dionin being rapidly reduced 
as conditions warrant. Hygienic measures and good 
feeding are also employed with vichy, stimulants, cola 
and other drugs to meet indications. He lays stress on 
the reeducation of the patient in self-control. 

THE METHOD OF SCELETH 

The patient is given a preparatory dose of saline 
cathartic. The basis of the medical treatment is the 
following : 

Scopolamin hydrobromid gr. 3 /loo 

Pilocarpin hydrobromate :••;••• & r - %2 

Ethyl-morphin hydrochlorid — (dionin).. gr. ss 

Fluidextract cascara sagrada TI\ xv 

Alcohol TTt xxxv 

Water qs. ad 3 i 

The dose is varied according to the extent of the 
addiction. Patients vary from 1 or 2 grains to as many 
as 60 to 90 grains a day of morphin. When more than 
10 grains of morphin per day arc being taken, 60 min- 
ims of the above mixture is given every three hours 
day and night for six days. On the seventh day the 
dosage is reduced to 30 minims, the eighth to 15 min- 



SCELETH TREATMENT OF MORPHINISM 405 

ims, and on the ninth 15 minims three times a day 
instead of every three hours day and night. On the 
tenth day the mixture is discontinued and strychnin 
nitrate, one-thirtieth grain, three times a day, is used. 
On the eleventh day strychnin nitrate, one-sixtieth of 
a grain, is given, and this is continued for a week. 
During the first five days only light diet is given, but 
patients are encouraged to take liquids freely. 

If a patient is using less than 10 grains of morphin a 
day, the dose should be 30 minims of the mixture to 
begin with. If he is using less than 5 grains, 15 minims 
is used as a starting dose. During the first three days 
the patients suffer from insomnia, and in about 10 per 
cent, of the cases vomiting; this is to be expected. If 
the pulse goes below 40 or over 120, the mixture is 
stopped for a single dose. If there is collapse, one- 
half grain of ethyl morphin hydrochlorid or one-fourth 
grain morphin is given hypodermically. In about 4 
per cent, of the cases of scopolamin delirium may 
develop. In such instances the mixture should be 
given without scopolamin for two doses, and then con- 
tinue with scopolamin in one two-hundredth-grain 
doses. 

During the treatment no other drugs should be used. 
After the fifth day the patients will have no further 
desire for morphin. Up to this time they care very 
little for food, but after the fifth day they develop a 
ravenous appetite and will gain weight rapidly. 
Extremely emaciated patients will gain a pound a day 
for the first thirty days. The patient should be directly 
under the physician's care, but after eleven days, the 
strychnin treatment of seven days may be safely 
entrusted to the patient. 

The final results are, of course, dependent on the 
cause of the addiction. If, since the beginning of the 
habit, the cause has been removed, the patients are 
permanently cured and do not return to the habit. 
Where the cause persists, whether it be functional 
neurosis, a degenerate mentality or criminality, the 
patient occasionally returns to be treated anew. The 
treatment of the cause should be borne in mind at the 
time any corrective treatment is undertaken. 



406 POISONOUS LEAD SALTS 

LEAD-POISONING 

In communities in which there are industrial plants 
handling lead, poisoning from this source is frequent. 
It has been shown that the most poisonous or the 
most soluble forms of lead are not necessarily the 
most likely to cause accidental poisoning. Those that 
most readily form dust seem to be most harmful, the 
more the dust is abolished, therefore, in all forms of 
lead factories and lead industries, the less poisoning. 
There is no question, of course, of the danger of lead 
fumes from molten lead. 

In an investigation of this subject Dr. Alice Hamil- 
ton (Jour. A. M. A., 1912, Sept. 7, p. 777) came to 
the conclusion that the most poisonous of the lead salts 
is probably the suboxid which forms on the surface of 
melted lead, is given off in fumes at high temperatures 
and also rubs off on the hands of the leadworkers ; it 
is this salt that causes poisoning in smelters, molders, 
type-setters, plumbers and others. The other forms 
most likely to cause poisoning are litharge or oxid of 
lead, and then the higher oxids of lead, as red lead, 
and the carbonate of lead, or white lead. Those who 
clean or scrape off lead paint, and also painters, are 
likely to have poisoning from white lead. Lead- 
poisoning occurs frequently in factories in which men 
work in white lead, and in oxid of lead or red lead, 
and Dr. Hamilton finds that those who work in red 
lead are poisoned sooner than those who work in 
white lead. 

wShe believes that a weak sulphuric acid lemonade, 
which workmen were urged to drink, is not a protec- 
tive against lead-poisoning. It has been proved that 
most forms of lead will be so acted on by the gastric 
juice during digestion that some lead will be absorbed. 
The only harmless lead seems to be the sulphid of lead. 

The amount of lead necessary to cause poisoning 
varies greatly, probably according to idiosyncrasy, 
some.persons being susceptible, others being tolerant. 
Some artisans, therefore, may work in lead for years 
without evidence of poisoning, while others can work- 
but a few weeks before poisoning is apparent. Inves- 
tigations in some of our factories. Dr. Hamilton says, 
showed that from 25 to 35 per cent, of the employees 



DIAGNOSIS OF LEAD POISONING 407 

had some form of lead-poisoning. Negroes seem 
more susceptible to lead than white men, and women 
are probably more susceptible than men. Fatigue, 
improper housing and insufficient food all render the 
individual more susceptible to lead-poisoning and its 
anemia, as we would logically conclude. Those who 
drink much alcohol are more susceptible to the poison- 
ing, and the tendency to drink beer or whisky in order 
to remove the sickish, disagreeable, sweet taste from 
the mouth due to the lead salts that are inhaled or 
swallowed is great with men in these employments. 
Women, on the other hand, drink a good deal of tea, 
or crave sour things, to overcome this disagreeable 
taste. 

It has not been shown that lead is positively absorbed 
from the skin, or that much is absorbed when inhaled 
into the lungs ; probably most of the poisoning is 
caused by lead being swallowed into the stomach. 

The diagnosis of chronic lead-poisoning is some- 
times difficult, and for that reason every one should 
be questioned as to his possible exposure to lead, after 
other more tangible causes are excluded, if he loses 
appetite, is pale or anemic, is constipated and suffers 
from indigestion. These are all prodromal symptoms. 
The blue line on the gums may or may not be present. 
If the teeth and mouth are properly cared for the blue 
line is probably not often found. "The basophilic 
granulation of the red cells," which was thought at 
one time to be diagnostic of chronic lead-poisoning, has 
been shown not to be pathognomonic. Lead may or 
may not be found in the urine of patients who show 
other signs of lead-poisoning; therefore its absence 
will not exclude lead-poisoning. It has been suggested, 
in cases in which the patient is working in lead and 
poisoning is suspected, that a soluble sulphid be rubbed 
on the skin, on the theory that lead is excreted through 
the skin, and that if a black precipitate is formed, it 
will show that there is lead in the tissues. 

Dr. Hamilton concludes that, although one attack of 
acute plumbism is not serious and may leave no dis- 
eased condition, one attack does predispose to another, 
and that probably a man who has had one attack of 
acute colic, for instance, or of wrist-drop, certainly 



408 TREATMENT OF LEAD PALSY 

should be ordered to stop working in lead, and that the 
employer should refuse him employment. The later 
pathology of chronic lead-poisoning becomes that of 
cardiovascular-renal disease on the one hand, or pro- 
gressive anemia, weakened muscles, especially the 
extensors, tremor and emaciation. 

In this anemia nucleated red corpuscles are almost 
always found, even if the anemia is not profound. 

Lead colic may occur suddenly, or after protracted 
constipation, with or without gastro-intestinal pains. 
During the paroxysm the patient generally vomits, the 
pulse is slowed and the blood-pressure is generally 
raised. Nothing will stop this kind of pain but large 
doses of morphin, used in combination with atropin. 
Hot fomentations to the abdomen should be used, or 
better, if the patient is able, a hot bath should be taken. 
As soon as the pain is less severe the patient should 
receive a saline cathartic, and best perhaps Rochelle 
salt, as, in spite of the usual innocuousness of mag- 
nesium sulphate, it should not be forgotten that, occa- 
sionally, if magnesium sulphate does not cause purg- 
ing and is absorbed, it can cause nervous depression 
not dissimilar to that which may occur from lead. 

The after-treatment of lead-poisoning of this nature, 
or if chronic lead-poisoning is diagnosed without lead 
colic occurring, is a daily morning dose of Rochelle 
salt or something similar and the administration of 
small doses of sodium iodid. The dose of iodid should, 
as a rule, be small, not more than 0.20 gm. 3 grains) 
three times a day, after meals, as large doses may cause 
more lead in the system to become soluble than is 
desired, and more acute symptoms of lead-poisoning 
to occur. Anything that builds up the nutrition is 
also good after-treatment for chronic lead-poisoning ; 
for example, the administration of small doses of iron, 
and the prevention of high blood-pressure and a possi- 
ble beginning cardiovascular-renal disease. 

Tf lead palsy, which in its most frequent form is 
wrist-drop, is present, the tonic treatment mentioned 
before should be carried out with the addition of 
strychnin and the use of electricity and massage. 

Acute cerebral symptoms not infrequently occur. 
These symptoms may be a delirium, convulsions, epi- 



DELIRIUM TREMENS 409 

leptiform in character, or more or less coma. Occa- 
sionally hallucinations and insanity are caused by the 
action of lead on the brain. These conditions are all 
exceedingly serious. While wrist-drop is generally 
curable, more profound paralysis of the arms and legs 
is much more serious. 

Prevention, of course, should be considered by every 
employer and should be understood by every employee 
who has anything to do with industries that make or 
handle lead. A patient who has once been poisoned 
by lead should either leave his occupation or should 
inaugurate such means of prevention of future poison- 
ing as are efficient. Personal cleanliness is one of the 
greatest factors in the prevention of lead-poisoning 

DELIRIUM TREMENS 

The use of alcohol, while not so general as a few 
years ago, is still sufficiently frequent to cause every 
physician to be mindful of its possible effect on every 
patient whom he is called to treat. In individuals who 
have habitually used considerable quantities of alco- 
holic stimulants, even although they may rarely, per- 
haps never have drunk to intoxication, the unfavorable 
effects of the chronic indulgence in alcohol are fre- 
quently seen when acute or chronic illness supervenes. 
Especially in the severe acute infections, like pneu- 
monia, the symptoms are frequently modified or added 
to by the effects of the habitual use of alcohol. 

In commencing the treatment in a case of this 
kind, the physician should inquire carefully, and con- 
sider the possible influence of the habitual use of alco- 
hol on the symptoms and course of the disease. 

A common characteristic of these cases is the loss of 
appetite, accompanied often by nausea and vomiting, 
so that it is difficult for the patient to retain either 
nourishment or medicine. If the stomach is irritable, 
it is necessary to give such gastric sedatives as bis- 
muth or bicarbonate of sodium, with such aromatics 
as capsicum or peppermint. The stomach being in a 
condition to retain food, abundance of light nourish- 
ment should be administered at regular intervals. Milk 
may be given hot or cold according to the preference 
of the patient ; but if he has no preference, preferably 



410 SEDATIVES IN DELIRIUM TREMENS 

hot. Other light foods should be given, as broths, 
gruels, or soups. If he is able to take solid food, 
easily digestible articles may be added, such as cus- 
tard, eggs, lamb-chops, or beefsteak. 

SEDATIVES 

At the first appearance of restlessness and insomnia 
the patient should be given the bromid of sodium in 
1-gm. (15 grain) doses, repeated every two, three, or 
four hours. In the evening when it is natural to desire 
that the patient should sleep, a more active hypnotic 
should be used. Chloral in a dose of 1 gm. (15 
grains), and repeated in one hour, if needed, will gen- 
erally prove effective in securing prolonged sleep, after 
which the patient's condition will frequently be found 
very much improved. 

Although chloral is undoubtedly the peer of all hyp- 
notic drugs, it is rated as a cardiac and circulatory 
depressant, and, as is well known, can cause heart 
failure and death. All hypnotics except morphin, how- 
ever, in sufficient doses to produce sleep, are cardiac 
depressants, and it is quite probable that a dose of 
chloral which is sufficient to produce sleep in a patient 
with delirium tremens is no more depressant than the 
dose of other hypnotics sufficient to produce sleep in a 
patient in the same condition. If the circulation is 
notably weak, however, other hypnotics may be 
selected. Paraldehyd has had a long period of 
approval. Its action is rapid, and many times satis- 
factory. If the dose is sufficient, there may be con- 
siderable circulatory depression for a short time. The 
various synthetic hypnotics, old and new, sulphonme- 
thane (sulphonal), sulphonethylmethane (trional) , 
diethyl barbituric acid (veronal), and sodium diethyl- 
barbiturate (veronal-sodium), all act more or less sat- 
isfactorily, but act much more slowly than do chloral 
or paraldehyd, and in doses that are sufficient will 
produce considerable later depression. A sufficient 
dose of scopolamin hydrobromid, hypodermatically, 
to cause sleep in this excited condition is also likely to 
cause depression. Also, there often is an increased 
susceptibility to any atropin or at ropin -containing drug. 



DRUGS IN DELIRIUM TREMENS 411 

so that the cerebral excitation may be increased by 
scopolamin. 

In cases of acute illness in which, on account of the 
history of alcoholic addiction, there is reason to believe 
that symptoms referable to the habitual use of alcohol 
are liable to supervene, the use of sedatives should be 
commenced early before any of the characteristic 
symptoms of alcoholism appear, and should be con- 
tinued until it is evident that there is no danger of 
prolonged insomnia and restlessness. 

In severe cases in which active delirium with hallu- 
cinations has supervened, energetic treatment is 
urgently demanded. Danger must be looked for in two 
or three principal directions. The circulation is threat- 
ened, owing to the weak action of the heart, which 
may result in edema of the lungs. At the same time 
the circulation in the brain is especially affected so 
that there is a passive congestion, with more or less 
edema. Added to this are the symptoms of exhaustion 
due to the insomnia and violent muscular agitation. 
Here there is urgent necessity of maintaining the 
nutrition of the patient by giving liquid nourishment 
at regular intervals. It is necessary also to watch the 
circulation carefully and to maintain the action of the 
heart. The use of alcoholic stimulants for this pur- 
pose, while still recommended by many, is of doubtful 
propriety at this stage of the disease. 

If there is serious cerebral excitement and hyp- 
notics in ordinary doses do not act, the best treatment 
is ergot, in some reliable aseptic form, injected intra- 
muscularly into the deltoid muscle, a syringe ful at a 
dose. One hour after this injection, a hypodermic 
injection of morphin may be given, not more than Y\ 
of a grain. 

Theoretically morphin is not good treatment when 
there is cerebral excitement, as the dose required to 
quiet such excitement is very large, while smaller 
doses tend to increase the excitement. Under the 
condition described, however, ergot given first to 
relieve congestion of the brain and spinal cord and 
followed by morphin, prevents the initial excitement 
of the morphin and projects the length of time which 



412 CEREBRAL EDEMA 

a given dose of morphin will act, and the outcome is 
satisfactory. 

CEREBRAL EDEMA 

If there are signs of cerebral edema, no treatment is 
better than, or so satisfactory as, the subcutaneous 
ergot? treatment. The ergot may be repeated in three 
hours, and then once in six hours for several doses, 
if it is required. The administration of ergot by the 
mouth for the action desired on the brain is absolutely 
unsatisfactory and cannot be relied on. Also, if the 
heart is weak, ergot is the drug indicated. 

In other words, if there is apparent edema of the 
brain, ergot; if there is cerebral excitement and the 
heart is efficient, chloral; if there is cerebral excite- 
ment and the chloral is unsatisfactory alone, add ergot; 
if there is cerebral excitement and the heart is weak, 
ergot and morphin. 

Strychnin is inadvisable as a stimulant in this con- 
dition. Aromatic ammonia may be given if a quickly 
acting stimulant is required. A saturated solution of 
camphor in an aseptic oil may be given hypoder- 
matically, if required, as a quickly acting stimulant. 
Strophanthin hypodermatically may be given, if deemed 
advisable. Digitalis, which does not act well for at 
least twenty hours, is generally not indicated. 

In the meantime, while these various dietetic and 
medicinal measures are being employed, the patient 
should be kept quiet, should be constantly watched, 
and should be frequently bathed with warm water, or, 
if strong enough, given hot baths. 

Kramer (Ohio State Med. Jour., March, 1914) 
found that 1 per cent, solution of sodium bromid might 
be injected intraspinally without immediate or remote 
harm to the nervous system. He employed this mea- 
sure in the treatment of delirium tremens, withdrawing 
fifty to sixty cubic centimeters of cerebrospinal fluid 
and injecting an equal quantity of a sterile 1 per cent, 
solution of sodium bromid. The patients as a rule 
displayed immediate improvement, with lessened 
delirium, within a few minutes after the injection. If 
relapses occur after a few days the injections are 
repeated. 



ILLUMINATING GAS POISONING 413 

PREVENTION OF ALCOHOLISM 

An interesting suggestion in the treatment of alco- 
holism has been advanced by Spitzig {Jour. A. M. A., 
Jan. 17, 1914) who has observed that many tipplers 
begin at an age when boyish habits and tastes yield to 
those of a man. At maturity the demand for carbo- 
hydrates is materially lessened and the appetite for 
alcohol replaces it in the tippler. There is sometimes 
a positive aversion to sugar. "The chemical relation 
of carbohydrates to alcohol is significant. Dextrose 
is convertible to carbon dioxid and ethyl alcohol. The 
combination of carbon, hydrogen and oxygen makes 
for increased nutrition whether it be derived from 
alcohol or indirectly from sugars and starches. The 
human organism when deprived of sufficient sugar 
seems of necessity to demand an increased supply of 
alcohol. Conversely, when the body is satiated with 
alcohol it has little need for carbohydrates." Based 
on this theory his treatment for chronic alcoholism 
consists in gradually withdrawing alcohol and replac- 
ing it in the diet with sugar. When there is a strong 
distaste for this he uses lactose, a dram every two 
hours, given in powder for the psychic effect. The 
gastric and nervous disturbances are appropriately 
treated and, after self-confidence is gained, all medica- 
tion ceases and sugar is gradually reduced. With care, 
glycosuria can usually be avoided. 

ILLUMINATING GAS POISONING 

Persons poisoned with illuminating gas should 
receive at once as much fresh air as possible ; the 
tongue should be drawn forward and if respira- 
tion is failing artificial respiration should be begun. 
The use of various devices has been advocated in 
such cases and a report on them has been issued 
by a committee appointed by the American Medi- 
cal Association and the United States Bureau of 
Mines. In selecting such a device the possibilities 
of the machine for harm should be considered. The 
machine should be investigated as to its capabili- 
ties of producing suction, too great inflation, or other 
injury. Ordinarily the most simple devices or simple 
methods like the Sylvester method will serve. 



414 TREATMENT OF GAS POISONING 

Venesection should be done from one arm, and from 
"a pint to a pint and a half of blood should be 
removed," and simultaneously a quart of physiologic 
saline solution should be transferred into the median 
basilic or cephalic vein of the opposite arm. Two 
hours later, if there is not sufficient improvement, 
venesection may be done again. Saline solutions should 
be given subcutaneously every two hours in quantities 
of one pint. Or perhaps better the saline should be 
given by the colon by the continuous method. Jones 
(Amer. Jour. Med. Sci., October, 1909) believes that 
these saline solutions "diminish toxemia, lessen the 
tendency to edema of the lungs, increase the affinity 
of the red cells for oxygen, and stimulate the circula- 
tory system." 

As soon as possible after the patient has been dis- 
covered Jones advises the hypodermatic injection of 
2 c.c. (30 minims) of ether, 1/100 of a grain of atro- 
pin, and 2 c.c. (30 minims) of suprarenalin solution 
(1 : 1,000). He does not believe nitroglycerin or other 
vasodilators are indicated, but that vasoconstriction is 
what is needed. Dry heat should be applied to the 
body to prevent the loss of that necessity of life. 

If at any time the respiration or circulation fails, 
artificial respiration should be done again and circula- 
tory stimulants again administered. 

If the patient survives, the urine should be watched 
daily for some time that disturbances of the kidneys 
may be immediately noted. 

In all serious conditions of shock, coma and collapse, 
while everything that ought to be done should be done, 
there is a constant tendency to do too much, especially 
with drugs hypodermatically. Jones does not caution 
against the over-use of atropin or suprarenal prepara- 
tions, but simply states that the suprarenalin should be 
repeated when indicated. If the suprarenal solution is 
injected hypodermatically the blood will acquire the 
vasoconstricting material slowly and continuously for 
a long time. Therefore it would be inadvisable to 
inject a suprarenal solution too frequently, especially 
as the dose he first advises, 2 c.c. of a 1 : 1,000 supra- 
renal solution, is very large, in fact, large enough for 



SUNSTROKE 415 

serious consequences if the blood acquired it too 
rapidly. 

He also does not state how often the ether should 
be administered, and it would seem that the secondary 
effect of ether would be that of a vasodilator, although 
the primary effect is quick and immediate stimulation. 
In other words, after the attempt to quicken the cir- 
culation or awaken a patient by the stimulation of 
ether hypodermatically it would seem inadvisable to 
repeat it frequently. 

Also 1/100 of a grain of atropin hypodermatically 
should not be repeated frequently, certainly not for a 
number of hours. 

It is not clear, if there is circulatory failure, why 
the hypodermatic use of strychnin is not advised. 

As a circulatory and cerebral stimulant caffein 
should be considered, and also the hypodermatic use 
of a saturated solution of camphor in sterilized 
olive oil. 

HEAT PROSTRATION AND SUNSTROKE 

It is customary to divide the cases of illness due 
to excessive exposure to high temperature into two 
classes : one is distinguished as heat exhaustion ; the 
other as sunstroke, or thermic or heat fever. It is 
important to recognize the distinction between these 
two classes of cases, as their treatment is entirely 
different and distinct. 

Heat exhaustion is considered by many as a milder 
affection, although it frequently results in death. It 
may occur in those who are not exposed to the direct 
rays of the sun, but who are engaged in occupations 
which are accompanied by unusual heat, such as 
bakers, laundrymen, and foundrymen. It is associated 
with vasomotor paralysis. The beginning symptoms 
usually are dizziness, slight headache and throbbing 
in the head, nausea, and sometimes diarrhea ; these 
symptoms increasing, the patient becomes cold, the 
skin becomes pale and clammy, great prostration 
ensues, the patient is restless, and may become uncon- 
scious. The temperature is usually subnormal, and is 
never elevated. The pulse is weak. 



416 TREATMENT OF HEAT EXHAUSTION 

TREATMENT OF HEAT-EXHAUSTION 

The treatment of this condition embraces removal 
of the patient from the influence of the excessive heat 
to which he has been subjected. If he has been out 
of doors in the sun, he should be immediately removed 
to the shade, and as quickly as practicable be taken 
into a house or to a hospital. He should be placed 
in bed in a room which is cool and well ventilated. 
The clothing should be loosened so as not to interfere 
with respiration or circulation, and his working clothes 
should be removed, and hot applications, such as hot 
water bottles or hot bricks, should be placed around 
his extremities so as to restore the circulation and 
make him warm. If he is unconscious so that he 
cannot swallow, inhalations of ammonia should be 
given by the nostrils. Cold applications, either cold 
cloths or an ice-bag, should be made to the head; a 
mustard paste should be applied to the back of the 
neck and over the spine ; and if the respiration is 
obviously impaired, a hypodermatic injection of 1/100 
of a grain of sulphate of atropin should be admin- 
istered. If the heart is weak, a hypodermatic injec- 
tion of 1/30 of a grain of strychnin sulphate should 
be given. As soon as the patient is able to swallow, 
he should be given half an ounce or an ounce of 
whisky, unless he was already under the influence of 
this drug before the attack came on. If the circula- 
tion is improved, the body becomes warm, and the 
patient regains consciousness. 

A stimulating enema may be administered to move 
the bowels. The condition of the bladder should be 
investigated, and if the secretion of urine is scanty, 
the patient should be given copious draughts of water, 
and a little later an attempt should be made to give 
him nourishment, preferably in liquid form, and pref- 
erably hot, or at least warm. 

In the second class of cases which are termed sun- 
stroke or heat fever, the patient will be found in an 
entirely different condition. Usually on the arrival 
of the physician the patient will be found to be exceed- 
ingly hot, with a dry skin, a congested face, with 
veins swollen and arteries throbbing. The patient's 
temperature will usually be found elevated to from 



TREATMENT OF SUN STROKE 417 

105 to 110 degrees, or even higher. There is great 
restlessness ; the breathing may be stertorous ; the pulse 
is full and rapid ; the pupils, dilated at first, may 
become contracted, and unconsciousness may rapidly 
supervene. These symptoms may have come on with- 
out very much premonitory warning. They require 
prompt and active treatment. 

TREATMENT OF SUNSTROKE 

As in cases of heat exhaustion, if the patient is in 
the sun, he must at once be removed to the shade, and 
as soon as practicable to a cool and well-ventilated 
room. His clothing having been removed, and his 
temperature having been taken, he should, if prac- 
ticable, be at once placed in a tub of water at a tem- 
perature of 80 F., to which ice should be gradually 
added. At the same time, ice should be applied to the 
head. While the patient is in the ice-bath, he should 
be rubbed vigorously to promote the peripheral cir- 
culation and bring the hot blood to the surface of the 
body where it may be cooled. The temperature should 
be taken in the rectum every fifteen minutes, and as 
soon as it has fallen to 102 the patient should be 
removed from the bath; otherwise the temperature 
may continue to fall until it becomes subnormal, and 
the patient may pass into a condition of collapse. 
Ordinarily this bath should not be continued longer 
than from twenty to forty minutes, but it may be 
repeated after an interval of two, three or four hours 
if the temperature should again become elevated. In 
some of these cases in which it is obvious that a con- 
gestion of the internal viscera is embarrassing the 
action of the heart, venesection may be performed, 
and a pint of blood may be removed. This loss of 
liquid from the circulation may subsequently be 
restored by the injection of physiologic saline solu- 
tion, if it is deemed advisable. 

If there seems to be a tendency to edema and 
congestion of the lungs, a hypodermatic injection 
of 1/100 of a grain of atropin sulphate should be 
administered. 

If, after the temperature has commenced to fall, 
the pulse becomes weak, a hypodermatic injection 



418 ALKALINE THERAPY IN SUN STROKE 

of 1/30 of a grain of strychnin sulphate may be 
administered. 

If the elevation of the temperature is not so great, 
or if the use of the bath is impracticable, the patient 
may be laid on a cot, over which a rubber blanket 
has been placed, and a sheet rung out of cold water 
may be wrapped about him. He may then be rubbed 
with ice. After the sheet has become warm it may 
be removed and another one which has been allowed 
to soak in cold water may be substituted for the first. 

In some cases it may seem wise to administer an 
antipyretic drug. Acetphenetidinum may be used, but 
its action should be carefully watched. In most cases 
the cold bathing is far preferable to the use of any 
antipyretic drug. 

Woolley (Nezv York Med. Jour., 1914, xcix, p. 1165) 
believes that to replace the water lost to the body 
before the attack, and to increase elimination, there 
is no better method than infusion of saline solutions. 
If it is true that the oxygen content of the body is low 
and the acid content high, then such solutions should 
be alkaline. Woolley believes that such alkaline solu- 
tions as those recommended by Fischer are extremely 
efficacious whether given by rectum or intravenously, 
in neutralizing the acids of the body and increasing 
water elimination by the kidneys. The solution for 
rectal use he urges should be prepared as follows : 

Sodium chlorid 30 gm. 

Sodium carbonate (crystallized).. 20 gm. 
Water 1,000 c.c. 

The injection should be given slowly enough to 
allow retention. The time consumed in injecting a 
liter should not be less than one hour. 

For intravenous injection the following solution may 
be used : 

Sodium chlorid 14 gm. 

Sodium carbonate (crystallized)... 10 gm. 
Water 1,000 c.c. 

This also should be given very slowly. 

The effect of these solutions on the secretion of 
urine, Woolley states, is remarkable, and as a rule 
they will make it unnecessary to use digitalis. When 



AFTER EFFECTS OF SUN STROKE 419 

this latter drug is used, it should be very carefully 
administered and its effects carefully watched. The 
use of strychnin is not advised in the active stage of 
the disease. 

Such treatment will dispose of the immediate dan- 
ger, and when this has been done treatment is symp- 
tomatic. In apyrexial heat exhaustion external hydro- 
therapeutic measures are uncalled for, and treatment 
should be eliminative and stimulative. The internal 
hydrotherapeutic methods should be very useful in 
these cases and should be combined with friction, mas- 
sage, warm packs with sufficient internal stimulant 
medication. After recovery from an attack of insola- 
tion great caution must be observed by the patient to 
prevent recurrences from subsequent exposures to heat. 

AFTER EFFECTS 

Persons who have been the victims either of heat 
exhaustion or of heat fever often suffer more or less 
from the effects of heat during the remainder of their 
lives. It is always wise to warn patients or their 
friends of this possibility, and to direct them to avoid, 
as far as possible, exposure to the direct rays of the 
sun or to overheated rooms during the summer. They 
should be advised to practice cold bathing, and, 
if possible, sea bathing during the summer months. 
Sometimes the administration of tonics, and especially 
quinin sulphate combined with strychnin sulphate or 
extract of nux vomica, has seemed to aid these per- 
sons in withstanding the effect of the summer heat. 
Persons who seem to be predisposed to be affected by 
the heat should avoid exposing themselves as much 
as possible. They should dress lightly, should drink 
plenty of water, should avoid indulgence in alcoholic 
drinks, should keep their heads as cool as possible ; 
and some recommend that the back should be protected 
by sewing an extra piece of flannel into the inside of 
the shirt so that it may protect the spinal cord. These 
precautions may wisely be observed by everyone in 
hot weather, and especially when an excess of humidity 
in the atmosphere diminishes the perspiration of those 
who are w r orking, or are exposed to very hot air. 



420 ASPHYXIA 

Some patients who have suffered severe sunstroke 
find that their memory is greatly impaired afterward, 
and that they never have the same mental ability and 
memory. Little can be done to benefit this condition, 
but if one feels that he should give the patient some- 
thing in the hope that it may do some good, probably 
nothing will be more likely to prove beneficial than 
the glycerophosphate of calcium or some form of 
phosphorus. 

Not infrequently infants and young children suffer 
from the effects of extreme heat. This condition 
should be looked for in children who are suddenly 
taken ill in the hot weather without any apparent 
reason. If they are found suffering from a high tem- 
perature for which no other explanation can be found, 
and if the history of the case shows that they have 
been exposed to high temperature, they should be 
placed under favorable conditions in a cool, airy 
room, and given a sponge bath of cool water, and cold 
drinks should be administered. If the heart becomes 
weak, small doses of whisky, well diluted, may be 
administered. 

Sometimes after exposure to excessive heat there 
is twitching of the muscles, and even severe convul- 
sions. When the convulsions occur and continue they 
may be controlled by a hypodermatic injection of 
Y\. grain of morphin with 1/150 grain of atropin. If 
they resist this treatment, the patient may be anes- 
thetized by the administration of chloroform, or a 
rectal enema containing 2 gm. (30 grains) of bromid 
of sodium and 1 gm. (15 grains) of hydrated chloral 
may be administered and repeated, if necessary, after 
one hour. 

ASPHYXIA 

ASPHYXIA FROM SUBMERSION : DROWNING 

Most individuals who become asphyxiated from sub- 
mersion in water or from drowning are dead when they 
are taken out of the water, and all efforts to restore 
them to life are futile. This is especially the case if 
complete submersion has lasted four or five minutes. 
The occasional instance of the successful treatment of 
this form of asphyxia, however, make it incumbent on 
the physician to be thoroughly informed as to the 



TREATMENT OF DROWNING 421 

best methods to employ in the treatment of these cases, 
and to be prepared to carry them out if he happens to 
be near by when the patient is taken out of the water. 

In the first place, the water must be expelled, so far 
as possible, from the respiratory passages. Probably 
there is no better way of doing this than by inverting, 
the patient by taking hold of his feet and raising them 
up and letting his head hang down. This is a simple 
maneuver, provided the bystanders have strength 
enough to carry it out. Rolling the patient on a barrel 
is a crude and harsh substitute. Having removed the 
water as far as possible from the chest, the next thing 
to do is to perform artificial respiration. There are 
a number of methods of doing this. 

The so-called method of Marshall Hall was first 
described in 1858, and consists in rolling the patient 
alternately from the lateral to the prone position and 
pressing on the back between the shoulder blades when 
he is in the latter position. This has the advantage that 
the tongue does not fall back into the throat and so 
obstruct the larynx, and the water and mucous are able 
to flow out of the mouth. 

The following year the so-called Sylvester method 
was described. This consists in allowing the patient to 
lie on his back with his shoulders raised and his head 
hanging low. The operator then takes hold of the 
arms of the patient above the elbows and draws them 
gently away from his body until they arrive at a point 
above his head. This raises the ribs and increases the 
capacity of the chest. The arms then are carried down 
by the side and the elbows flexed and pressed against 
the lower part of the chest, thus diminishing the 
capacity of the chest and driving the air out. In this 
method the tongue is likely to fall back into the throat 
and interfere with respiration unless some one grasps 
it and pulls it forward. 

In 1868, Dr. B. Howard of New York described a 
method of treating these cases which consists in lay- 
ing the patient on his back while the physician kneels 
over the lower part of the body and presses on the 
lower part of the chest so as to diminish its capacity. 
He then relaxes the pressure, and the natural elas- 
ticity of the chest increases the air capacity. In this 



422 SCHAEFER METHOD 

method also the tongue is liable to fall backward, and 
must be drawn forward. It is objected that in elderly 
patients the ribs are brittle and may be fractured, and 
that the liver is congested and may be ruptured. 

Finally it remains to describe the method known as 
that of Professor E. A. Schafer, professor of physi- 
ology in the University of Edinburgh. He recom- 
mends that the patient be placed in the prone position. 
The physician being astride the patient, the open hands 
are placed on either side of the lower ribs and firm, 
but not violent pressure is exerted. This may be done 
by allowing the weight of the body to come on the 
arms. After this pressure has been exerted for three 
seconds the body may be brought upward and the pres- 
sure relaxed. This should be repeated at intervals of 
five seconds, or twelve times in a minute. 

Schafer made investigations with a view to compar- 
ing the utility of the various methods of artificial res- 
piration. He found that in natural respiration the air 
exchanged in a minute by a person breathing thirteen 
times a minute was 5,850 c.c. The amount of tidal air 
at each breath therefore would be 450 c.c. Employing 
the Sylvester method, the amount of air exchanged in 
a minute was 2,280 c.c, showing the tidal air of each 
breath to be only 175 c.c. With the Marshall Hall 
method the exchange of air was 3,300 c.c, with a tidal 
air volume of 254 c.c. With the Howard method the 
exchange per minute is 4,030 c.c and the tidal air 
volume 310 c.c With his own method he was able to 
pump through the lungs per minute 6,760 c.c, showing 
a tidal air volume of 520 c.c He therefore believes 
that this is the most efficient method of performing 
artificial respiration. He states that the advantages 
are : "1, it is fully efficient ; 2, it can be performed with- 
out fatigue by a single individual; 3, it is simple and 
easily learned ; and 4, it allows the tongue to* fall for- 
ward, and the mucus and water to escape from the 
mouth, so that the tendency of these to block the pas- 
sage of air, which is inherent to the supine position, 
is altogether obviated/' 

This subject was discussed at considerable length by 
Professor Schafer in The Journal of the American 
Medical Association, Sept. 5, 1908, page 801. 



ARTIFICIAL RESPIRATION 423 

In treating these cases it is important to preserve so 
far as possible the warmth of the patient. Woolen 
blankets should be obtained, and, after the surface of 
the body has been thoroughly dried, wrapped about 
him. While artificial respiration is being employed, 
friction of the surface of the body, especially from the 
extremities toward the center, should be carefully but 
not roughly done. It is recommended that artificial 
respiration should be continued for from one to two 
hours, but it seems that there is very little use in con- 
tinuing efforts to restore respiration after the action of 
the heart has ceased. As long as the action of the heart 
continues the artificial respiration should be continued, 
regularly and systematically. 

Some hOvSpitals are establishing apparatus for pro- 
moting and compelling respiration in patients who have 
from ether, chloroform or other causes, ceased to 
breathe. In the consideration of gas poisoning it was 
pointed out that the use of these devices may at times 
be attended with danger. In selecting such devices 
for permanent installation, physicians should advise 
only those of simple mechanism and guaranteed safety. 



DISEASES OF THE EYE 



OPHTHALMIA NEONATORUM 

The prevention of this inflammation of the eye is of 
national importance, and should be understood and car- 
ried out by every practitioner who takes charge of 
obstetric cases. The use of Crede's method has secured 
an immense reduction in the number of these cases. 
It should be remembered, then, that by this means this 
disease is practically absolutely preventable. 

PROPHYLAXIS 

As soon as the child is born and after thoroughly 
cleansing the eyes, instill a drop of a 1 per cent, nitrate 
of silver solution. While Crede advised the use of a 
2 per cent, solution, it is generally believed that the 
1 per cent, is of sufficient strength. This may be fol- 
lowed by a little physiologic saline solution or a drop 
of adrenalin chlorid solution (1:5,000). This "stops 
the pain and neutralizes the further action of the sil- 
ver/' Other more modern silver preparations have 
also been advised, as 25 per cent, argyrol or 10 per 
cent, protargyrol, but they are probably not so reliable 
as the silver nitrate. 

ACTIVE TREATMENT 

If in spite of such prophylactic treatment the con- 
junctivae may become inflamed, the conjunctivce 
should be thoroughly cleansed. The lid of the eye is 
gently raised, all pressure being avoided, and the tip 
of a soft rubber bulb syringe is inserted under the 
upper lid. Slowly and gently the eye is irrigated with 
a saturated cold boric acid solution to wash out all 
purulent matter. This should be done every fifteen 
minutes, or oftener if the discharge is profuse. Mer- 
curic chlorid (1:10,000), normal saline solution, or 
sterile water may also be used as cleansing agents. 

Iced compresses of boric acid solution may be applied 
to secure lessened inflammation and relief from pain. 



BLEPHARITIS 425 

Continuous refrigeration, however, should be avoided 
to prevent loss of nutrition which may result from it. 
If the cornea is involved hot applications and instilla- 
tion of atropin is generally advised. 

In the treatment of these cases silver nitrate is the 
drug of chief reliance. Once each day during the 
course, especially while there is a purulent discharge, 
a 1 or 2 per cent, solution of silver nitrate should be 
brushed on the everted conjunctiva. If eversion of the 
lids is extremely painful, they may, at first, simply be 
raised and the silver nitrate solution applied with a 
well-protected swab. 

Every three or four hours a few drops of argyrol 
solution in strength of from 25 to 50 per cent., or 
protargyrol, 10 per cent., may be instilled into the eye. 

If the discharge and inflammation persist, it may be 
necessary to consider surgical procedures or specific 
treatment of the complications. The disease is a serious 
one and the services of a specialist may be required 
early in its course. 

BLEPHARITIS 

The occurrence of inflammations of the lids has 
been associated with numerous causes, chiefly general 
debilitated condition of the body, following infectious 
diseases, lack of cleanliness and errors of refraction. 
Bad hygienic surroundings, lack of sleep, irritating 
atmosphere due to dust, heat, smoke or other causes 
and insufficient light also play a part in some cases. 

The correction of these general causes is important, 
more important perhaps than any local treatment. 
Local cleanliness and removal of any bad eye-habits 
should be attempted and persisted in. Errors of 
refraction should be corrected and referred to a com- 
petent refractionist for prescription. The occupation 
of the patient as a source of irritation should be thor- 
oughly investigated. 

In securing cleanliness of the eyes, the edges of the 
lids should be washed with soap and water, or water 
and borax, or solutions of hydrogen peroxid, removing 
all crusts if possible without serious injury. As 
sedative eye washes, Brav recommends the following : 



426 TREATMENT OF BLEPHARITIS 

gm. or c.c. 

fy Acidi borici 2| 3 ss 

Zinci phenolsulphonatis |15 or gr. ii 

Aquae camphorae 151 AS ss 

Aquam destillatam ad 100] flSHi 

M. Sig. : Bathe the eyes with this solution, three times 
daily. 

Also efficient is the following used as eye drops : 

gm. or c.c. 

I£ Acidi borici |25 gr. v 

Aquae camphorae 15 or A3 v 

Aquam destillatam ad 25 1 AS i 

M. Sig. : Place two or three drops in each eye three or 
four times a day. 

Massage of the lids is a therapeutic measure of wide 
usage in this condition. Among various ointments 
advised adeps lanae hydrosus (lanolin), ammoniated 
mercury, 2 per cent, yellow oxid of mercury, and 
ichthyol have been commended. Gentle massage by 
horizontal stroking movements on the closed lids with 
the index finger, carried from the inner to the outer 
angle of the palpebral fissure, and lasting from three 
to five minutes, relieves venous congestion and stimu- 
lates the activity of the lymphatics, and absorption of 
inflammatory products is increased. This ointment, or 
vaselin if preferred, will soften the scales and allow 
them to be removed, thus aiding in getting rid of the 
blepharitis. Such massage is best done at bedtime, 
when some of the ointment may be left on the lids. In 
the morning the ointment may be washed off, and with 
it will come many of the scales. The yellow oxid of 
mercury seems to be a most valuable medicament for 
healing the lesions of this inflammation. It may be 
ordered as follows : 

gm. 

I£ Hydrargyri oxidi flavi 10 gr. i 

Olei olivae q. s. or 

Petrolati 10 3 ii 

M. Sig. : Apply at bedtime as directed. 

This makes 1 per cent, of the yellow oxid of mer- 
cury. It should be remembered that the official yellow 
oxid of mercury ointment is 10 per cent. 



HORDEOLUM 427 

Brav believes that in some cases salicylic acid oint- 
ment has a more favorable action, especially when there 
is much itching of the lids, as : 

gm.^ 

B Acidi salicylic! 1 15 or gr. ii 

Adipis lanae hydrosi 10 1 3 ii 

M. Sig. : Apply as directed. 

If itching is very marked Brav uses a tannic acid 
ointment, as : 

gm. 

fy Acidi tannici 115 or gr. ii 

Petrolati 10| 3 ii 

M. Sig. : Use as directed. 

Occasionally he uses cocain as follows : 

gm. 

fy Acidi tannici 115 gr. ii 

Cocainae 10 or gr. i 

Petrolati 10] 3 ii 

M. Sig. : Use as directed. 

If the tannic acid preparations cause irritation they 
should be discontinued. If the itching persists, the 
dried secretion in the little glands should be carefully 
expressed from the ducts. 

In treating the ulcerative type of blepharitis, or 
more severe types, it may be necessary to pull out all 
the eyelashes before undertaking the treatment. The 
use of silver nitrate is advised in these severe forms, 
and applications are made once daily with a 1 or 2 per 
cent, solution. 

HORDEOLUM (STYE) 

The stye is a fairly common form of eye infection. 
It is ordinarily a staphylococcus infection of a sebace- 
ous follicle, around the lash, but may occur inside the 
lid as an internal hordeolum or suppurating chalazion. 

As the stye is, as has been stated, primarily a staphy- 
lococcus infection, its source should be looked for in 
lowered resistance due to local uncleanliness, general 
debilitation or constipation and errors of refraction. 

Attempts may be made to abort the stye by cold 
applications but ordinarily w T hen seen, it will be too far 
advanced for such a procedure. As in any other local 
infection, hot compresses may then be applied and 



428 IRITIS 

when pus manifests its presence by a yellowish appear- 
ance the pus should be evacuated, incising as freely as 
necessary, and the area may be cleaned up by a mild 
antiseptic washing. 

If the hordeolums occur in crops or tend to recur 
frequently, general treatment in hygienic matters is 
indicated, and the use of autogenous vaccines may 
serve to create a more or less permanent cure with 
immunity from further attacks. 

IRITIS 

Inflammation of the iris may be acute or chronic, 
primary or secondary in its origin, and associated etio- 
logically with syphilis, rheumatism, tuberculosis, gout, 
gonorrhea, malaria, diabetes, anemia or any of the 
acute exanthems. Iritis seldom occurs without a sim- 
ultaneous inflammation of the ciliary body. 

Besides the actual pathologic changes in the iris 
and neighboring structures there are ordinarily pain, 
lacrimation, interference with vision and a fear of 
light. Ordinarily the duration of the disease is from 
several weeks to several months. 

TREATMENT 

In the treatment of iritis both eyes should be placed 
at rest; smoked glasses may be worn. The patient's 
general condition should be regulated, the bowels con- 
trolled and sufficient sleep secured by the administra- 
tion of hypnotics or morphin if necessary. When the 
pain subsides the patient should be in the open air as 
much as possible. 

Needless to state, the primary condition associated 
with the ocular inflammation should be treated ener- 
getically. Syphilis, tuberculosis, gout and rheumatism 
are all conditions which demand active scientific treat- 
ment. 

The most important drug in the treatment of iritis 
is atropin, which should be used in sufficient dosage to 
produce a full physiologic effect on the pupil. In chil- 
dren it should be used with care to prevent poisoning. 
In general a 1 per cent, solution may be used, of which 
one drop is instilled into the eye every hour until the 
pupil is dilated. Following this one drop every eight 



TREATMENT OF IRITIS 429 

hours is used to secure continued action. In children a 
0.5 or 0.25 per cent, solution is advisable. When atropin 
is not well borne and causes unpleasant symptoms, 
Brav suggests the following mixtures : 

gm. or c.c. 

fy Duboisinae sulphatis 1035 or gr. y 2 

Aquae destillatae 10 1 A3 iiss 

M. Sig. : One drop instilled into the affected eye every 
eight hours. 

Or: 

gm. or c.c. 

fy Scopolaminae hydrobromidi. . |015 or gr. % 

Aquae destillatae 8| A3 ii 

M. Sig. : One drop instilled into the affected eye, three 
times daily. 

If undesirable symptoms from the action of atropin 
occur, such as very uncomfortable drying of the throat, 
palpitation, flushing of the face, and cerebral excita- 
tion, then the stronger atropins must be discarded and 
homatropin used. 

gm. or c.c. 
R Homatropinae hydrobromidi.. |40 or gr. vi 
Aquae destillatae 10| A3 iiss 

M. Sig. : One drop in the affected eye every hour. 

[If both eyes are inflamed, the strength of the above 
preparations, in order for a drop to be used in each eye, 
must be reduced.] 

During the course of the inflammation the tension 
of the eye must be carefully watched lest glaucoma 
develop, though a temporary increase in intraocular 
pressure is often seen. As soon as the eye shows 
increased tension, Brav thoroughly evacuates the bow- 
els, gives absolute rest, and stops the atropin. If the 
tension does not then in a few hours decrease he uses 
eserin, as : 

gm. or c.c. 

R Physostigminae sulphatis.... 1 03 or gr. ^4 
Aquae destillatae 8| A3 ii 

M. Sig. : One drop in the affected eye every hour. 

Brav says that it is not often necessary to have 
recourse to this treatment, and it is rarely necessary to 
employ surgery to prevent glaucoma from iritis. 



430 TREATMENT OF IRITIS 

The value of atropin in iritis is to dilate the pupil 
and thus to prevent posterior synechiae. It also con- 
tracts the iris, thus reducing congestion, and paralyzes 
the ciliary muscles, thus giving the iris absolute rest. 

If the pain from the inflammation is not stopped by 
the atropin, hot moist compresses, frequently changed, 
should be employed. Poultices are not needed. If the 
pain persists in spite of such treatment, leeches should 
be applied, one or two to the temporal region, care 
being taken to avoid the large blood vessels. If in spite 
of such treatment the deep-seated pain in the orbit con- 
tinues, so as to prevent sleep, morphin must be used, 
and best hypodermatically. 

If the iritis is due to rheumatism, salicylates are 
advisable; and Brav recommends the following: 

gm. or c.c 

R Sodii salicylatis 15 

Potassii iodidi 15 or § ss 

Syrupi sarsaparillae compositi 

aa 100 A3 Hi 

M. Sig. : A teaspoonful, with plenty of water, every four 
hours. 

Brav finds suprarenal solutions useless, and perhaps 
harmful. 

Cocain may be combined with atropin at times, as : 

gm. or c.c. 

I£ Cocainae hydrochloridi 103 

Atropinae sulphatis aa |03 or gr. ss 

Aquae destillatae 8| A3 ii 

M. Sig. : One drop instilled into the affected eye, every 
three or four hours, if necessary. 

The treatment of hypopyon or posterior synechia is 
a subject for a specialist. 

_As it is stated that at least 50 per cent, of iritis is 
caused by syphilis and that mostly in the secondary 
stage, constitutional treatment during such iritis is that 
of the syphilis, and mercury is the important drug. 
Brav thinks it is best administered in the form of an 
ointment, and advises the rubbing on of 4 grams (1 
dram) of the unguentum hydrargyri into the skin twice 
daily, choosing different parts of the body at each appli- 



BURNS OF THE EYE 431 

cation. If symptoms of mercurialism occur, of course 
the drug should be temporarily stopped, and during its 
administration alkaline mouth washes should be used. 

When the inflammatory symptoms are declining 
Brav finds potassium iodid of value in promoting the 
absorption of the inflammatory products. Syphilis 
having been the cause of the iritis, of course it must 
be long treated else the iritis may recur, as well as 
other symptoms of syphilis. 

If rheumatism is the cause of the iritis he would not 
only give salicylates, as intimated above, but during 
the height of the disease he would give large doses, 
as a gram of sodium salicylate (15 grains) every four 
hours, during the daytime. 

After the iritis has subsided, especially after anti- 
syphilitic or antirheumatic treatment, the patient gen- 
erally needs iron. 

BURNS OF THE EYE FROM LIME 

This form of accident occurs quite frequently, and is 
ordinarily followed by very grave results. The most 
serious and important sequel is the adherence of the 
lid to the globe (symblepharon) when there are two 
opposing raw surfaces. If the patient is seen immedi- 
ately after the accident, the first step in the treatment 
is to drop into the conjunctival sac a few drops of a 
1 per cent, solution of holocain, or of a 4 per cent, solu- 
tion of cocain, in order to relieve the pain, which is 
usually intense, and then to remove all the remaining 
particles of lime as quickly as possible. The irrigating 
fluid should be a weak solution of vinegar, to neutralize 
the caustic effect of the lime. Subsequently cold appli- 
cations should be applied to the closed lids, and a mild 
antiseptic, such as a 3 per cent, boric acid solution, 
dropped into the eye every two or three hours. If the 
burn is at all extensive, the conjunctival sac should be 
filled with an antiseptic ointment, which not only 
relieves the pain, but also prevents adhesion of the 
opposing surfaces. One of the best preparations for 
this purpose is a mercuric chlorid ointment which 
consists of mercuric chlorid (1 : 10,000) in petrolatum. 
Severe burns from lime, resulting in complete opacity 



432 BURNS OF THE EYE 

of the cornea, have been treated — in addition to the 
usual local treatment — by subcutaneous injections of 
sodium cacodylate (from 3 to 7 grains at a dose) with 
perfect results. 

After emergency treatment has been administered, 
if the case appears to be at all severe, the patient may 
well be referred to a specialist in such conditions. 






DISEASES OF THE EAR 



OTITIS MEDIA 

All kinds of bacteria may reach the middle ear, but 
the most frequent infections are the streptococcic and 
the pneumococcic. In a healthy ear the bacteria reach 
the tympanic cavity through the Eustachian tube, and 
this presupposes a nasopharyngeal infection and 
inflammation. Obstruction at the mouths of the Eus- 
tachian tubes, or swelling in the tubes, then inhibits 
the normal aeration of the tympanic chamber and pre- 
disposes to infection of the middle ear. Hence pro- 
phylaxis of middle-ear inflammations consists in the 
removal of obstructive adenoids in the nasopharynx, 
in the removal of obstructive hypertrophies of the 
nasal passages so as to cause proper nasal respiration 
and the correction, so far as possible, of nasal and 
nasopharyngeal chronic inflammations. 

In acute inflammations of the nose and nasopharynx 
when the Eustachian tubes are likely to become 
obstructed and bacteria are likely to reach the middle 
ear, a proper cleansing of the nose and nasopharynx 
with warm, mildly antiseptic and alkaline sprays and 
gargles is the proper treatment. Nasal douches as 
generally applied are likely to force fluid, pus and bac- 
teria into the middle ear, in fact, a douche should never 
be taken through the nostrils with any but the most 
gentle pressure. Snuffing mild, warm, alkaline fluids 
through the nostrils, or gently spraying and then 
snuffing, or possibly the pouring of such a fluid from a 
spoon or small vial into the notrils can do nothing but 
good and no harm to the Eustachian tubes. Or gentle 
spraying into the nasopharynx with such solutions or 
gargling and throwing the head forward so that the 
liquid washes the roof of the pharynx, will also remove 
products of inflammation, pus and mucus from these 
parts and from the mouths of the Eustachian tubes. 
Hektoen and Rappaport have shown that the insuffla- 
tion into the nose of kaolin will result in the removal 
of most of the bacteria. 



434 OTITIS MEDIA 

If middle-ear congestion occurs the diagnosis must 
be made as to whether serum or other fluid is present 
or not. If fluid is present, as shown by bulging of the 
tympanic membrane and by deafness, incision of the 
drum must be immediately made. If no fluid is present 
in the tympanic cavity, but the drum shows conges- 
tion and there is pain, the following ear drops may be 
used: 

gm. or c.c. 

Ifc Acidi borici 1 1 gr. xv 

Glycerini 25 1 or A3 i 

Aquam ad 50 1 A3 ii 

M. Sig. : Warm, and pour half a teaspoonful into the ear 
once in three or four hours. 

This fluid should be held in the ear a minute or two 
and then allowed to run out. The outer part of the 
canal is then gently dried with absorbent cotton and a 
plug of cotton left in the orifice. 

If preferred, either of the following prescriptions 
may be used : 

gm. or c.c. 

R Acidi borici ll gr. xv 

Glycerini 10 A3 iii 

Tincturae opii 5] or A3 iss 

Aquam ad 50] AS ii 

M. Sig. : Warm, and place a few drops in the ear every 
hour, if needed, and then plug with cotton. 

Or: 

gm. or c.c. 

B Epinephrini chloridi |03 gr. ss 

Glycerini 20 1 or A3 v 

Aquam ad 25 1 AS i 

M. Sig. : Warm, and pour half a teaspoonful into the ear 
every three hours. 

It should again be emphasized that treatment, even 
as simple as the above, should only be used to relieve 
congestion and pain, but such temporizing measures 
should not be used if the drum is bulging and there is 
liquid in the middle ear. The only treatment for this 
condition is incision. 

Treatment after incision or after perforation of the 
drum, or of mastoid congestion, and of mastoid inflam- 
mation, belongs to the specialist. The restoration of a 
perfect drum and the recovery of perfect hearing after 



SOLUTIONS FOR USE IN EARS 



435 



middle-ear disturbance, and especially after mastoid 
inflammation, marks a success as great as in any branch 
of medicine. The general physician's duty ends when he 
has referred a patient with either acute or chronic ear 
disturbance to the specialist, and after he has impressed 
on his patient that the time to prevent, if possible, 
deafness and the danger of a possible cerebral abscess 
is now. If the patient neglects his own treatment after 
warnings, he has only himself to thank, but let him 
never be allowed the opportunity to blame his physi- 
cian. 



B 



SOLUTIONS FOR USE IN THE EARS 



gm. or c.c. 



Cocainae hydrochloridi 20 

Sodii boratis 50 

Solutionis epinephrini (1 : 1,000) 5 

Glycerini ajL 5 

Aquae camphorae q. s. ad 50 

M. Sig. : Ear drops. Warm before using. 

gm. or c.c. 

I£ Cocainae hydrochloridi 0| 15 

Acidi borici 0|25 c 

Glycerini 10| 

Aquae q. s. ad 25 1 

M. Sig. : Ear drops. Warm before using. 

gm. or c.c. 

I£ Acidi borici 2 

Tincturae opii 10 

Glycerini 20 

Aquae q. s. ad 50 

M. Sig. : Ear drops. Warm before using. 

gm. or c.c. 

I£ Epinephrini chloridi 0|03 

Glycerini 20| or 

Aquae q. s. ad 501 

M. Sig. : Ear drops. Warm before using. 



or 



gr. iv 
gr. x 

A3 iss 

flSii 



gr. in 
gr. v 
fl3iii 
flSi 



gr. xxxv 

A3 iii 
flSvi 
flSii 



gr.^2 
flSvi 
flSii 



DISEASES OF THE SKIN 



PRURITUS : ITCHING 

Pruritus, or itching, represents one of the most puz- 
zling problems in medicine. The clinical manifesta- 
tions are connected with the terminations of the sen- 
sory nerves in the epidermis. Many believe that it is 
associated with hyperemia and inflammation, this con- 
dition sometimes resulting in atrophy, with a continu- 
ance of itching. There are many reasons for believing 
that these pathologic conditions are not the efficient 
cause of the itching in many cases. For example, 
Oxyuris vermicalaris, or pin-worm, causes pruritus in 
children without any local lesion or disturbance in the 
nutrition of the skin evident on inspection, and the pru- 
ritus is probably not due to the presence of a foreign 
body on the skin. It is also a question whether the 
itching produced by pediculi, or lice, is due alone to 
their presence on the skin in a quiescent state or even 
in active movement. The rapidity with which the itch- 
ing in scabies subsides under sulphur treatment indi- 
cates that it is due to something besides the presence 
of a foreign body. Itching produced by a bite of a 
mosquito is out of all proportion to the local conges- 
tion and inflammation and is no doubt due to some 
poison injected by the mosquito. The itching associ- 
ated with jaundice dependent on obstruction to the 
flow of bile into the intestine is due to the irritation of 
the ends of the sensory nerves by some substance 
absorbed from the bile into the blood. The itching in 
urticaria, due usually to the ingestion of some unusual 
article of food, is probably caused by some poison 
carried to the nerve-endings in the blood as in the case 
of jaundice. 

It will be noted that many diseases accompanied by 
congestion and inflammation of the skin cause itching, 
but it is a curious fact that syphilis, which is con- 
stantly accompanied by cutaneous lesions, has a strik- 
ing characteristic that its skin' lesions are usually unac- 
companied by itching. 



MANAGEMENT OF PRURITUS 437 

With certain general diseases pruritus is a common 
symptom, especially diabetes and that common condi- 
tion associated with abnormal metabolism, known as 
lithemia, and which is believed by many to be asso- 
ciated with gout. These diseases are all characterized 
by the presence in the blood of chemical bodies, which 
ordinarily do not belong there. 

It is taught that pruritus may be of central origin. 
It is asserted to be of not infrequent occurrence in 
hypochondriasis and hysteria. Still another form is 
described as being of psychic origin, and is seen in 
insane persons who have hallucinations of the presence 
of parasites, such as pediculi, on the skin ; hallucina- 
tions which it is often difficult to remove, and which 
are sometimes removed only after repeated applications 
of antipruritic remedies. 

MANAGEMENT 

In undertaking the treatment of a case of pruritus it 
is necessary to investigate every organ of the body so 
as to restore to its normal action, if possible, any 
organ which may be acting abnormally or which may 
be under abnormal conditions. First, the condition of 
the digestive organs must be carefully investigated, and 
the diet must be carefully regulated. There are two 
types of people in whom pruritus is seen : one is the 
stout, robust, plethoric person who is continually over- 
eating, and the other is the thin, hungry person who is 
continually starving himself. In the case of the former 
the diet should be cut down. The protein substances 
should be greatly reduced, and the starches and sugars 
should be considerably limited. If it is found that cer- 
tain articles of food are not completely digested but 
give rise to fermentation, such articles should be 
reduced to an amount that can be taken care of by the 
digestive organs. In the latter class, the thin patients, 
fatty articles of food should be advised, and an ade- 
quate amount of protein should be given to afford 
adequate nourishment. In both classes, fruits, espe- 
cially oranges and grapes, will be found exceedingly 
useful. 

If the bowels are constipated, measures should be 
taken to make them act regularly and .abundantly. 



438 ELIMINATION IN PRURITUS 

Small doses of calomel, for a week or two, are some- 
times useful for this purpose. If calomel is thought 
to be undesirable a saline as 1 or 2 drams of magnesium 
sulphate or sodium phosphate may be given in half a 
glassful of water in the morning before breakfast. 

ELIMINATION 

Pruritus is frequently associated with deficient elim- 
ination, and especially of the kidneys. If the condition 
of the urine is found to indicate such defective elimina- 
tion, the internal use of alkalies will generally be found 
of advantage. In the case of the plethoric individual, 
with a strongly acid urine of high specific gravity, the 
following prescription may be used: 

gm. or c.c. 

ty Potassii citratis 40| 3 ix 

Aquae menthae piperitae 200| or AS vi 

M. Sig. Two teaspoonfuls, in water, three times a day, 
after meals. 

If the above dose, three times a day, does not alka- 
lize the urine (if that is the object desired), it may 
be administered four times a day. 

Although it is admitted that pruritus is associated 
with the sensory nerves, and it is claimed that in some 
instances it is due to a disturbance of the central ner- 
vous system, no drug acting on the brain, spinal cord 
or nerve trunks is very effective in pruritus, possibly 
with a single exception of bromids, which really act by 
dulling the peripheral endings of the nerves. The treat- 
ment of pruritus with bromids is generally inadvisable, 
as they act by causing nerve debility and later muscle 
debility and loss of nutrition. Temporarily such treat- 
ment is often good treatment. 

LOCAL APPLICATIONS 

Generally, in order to stop the itching, it is necessary 
to apply some drug to the skin which will lessen, the 
sensibility of the ends of the nerves which are in 
trouble. Several drugs are used for this purpose. The 
most useful are phenol (carbolic acid), menthol, cam- 
phor, chloral, thymol, oil of cade, alcohol and alkalies. 






LOCAL APPLICATIONS FOR PRURITUS 439 



The following are a few prescriptions which are sug- 
gestive. Various modifications of any one of them 
may act satisfactorily. 



gm. or c.c. 

n Phenolis 51 

Liquoris potassae aa 5| or 

Petrolati liquidi q. s. ad 50 1 

M. Sig. : Use externally as directed. 
Shake. 

Or: 

gm. or c.c. 

3 Phenolis 31 

Glycerini 10| or 

Liquoris calcis 251 

Aquae q. s. ad 100 1 

M. Sig. : Sponge over irritated surfaces. 
Shake. 



Or: 



gm. or c.c. 

Phenolis 25 

Liquoris calcis 125 

Oleum amygdalae dulcis..ad 250 

Sig. : Use externally as directed. 



M. 

Or: 

gm. or c.c. 

$ Mentholis |50 

Sodii bicarbonatis 15| or 

Glycerini 251 

Aquam ad 250| 

M. Sig. : Use externally as directed. 
Or: 

M. 
Or 

& 



Mentholis 

Camphorae 

Olei amygdalae dulcis 2 

Adipis lanae hydrosi. ....... 25 

Sig. : Use externally. 



gm. or c.c. 

1 50 
1 



or 



gm. or c.c. 



Mentholis 

Phenylis salicylatis 2| 

Olei amygdalae dulcis 2| 

Adipis lanae hydrosi 20| 

M. Sig. : Use externally. 



30 



flSiss 
flSii 



A3 i 

fl3iii 

flSi 

flSiv 



ftfvi 
flSiv mm 
A3 viii 



gr. vn 

3 ss 
fl3vi 

flSviii 



gr. x 
gr. xviii 
TTi, xxxv 
3i 



gr. v 
3 ss 

fl3ss 
3v 



440 LOCAL APPLICATIONS FOR PRURITUS 
Or: 



S ss 



gm. or ex. 

I£ Camphorae 15 1 

Chlorali hydrati aa 15| or 

M. Sig. : Paint over affected part. 

Or: 

gm. or c.c. 

I£ Mentholis 1 gr. xv 

Thymolis 2 or gr. xxv 

Aquae 100 A3 iii 

M. Sig. : Use externally. 

Or: 

gm. or c.c. 

B Camphorae 5 gr. lxxv 

Zinci oxidi 15 or S ss 

Cretae preparatae 30 Si 

M. et fac chartulam 1. 

Sig. : Use as a dusting powder. 

Or: 

gm. or c.c. 

B Camphorae 5 gr. lxxv 

Zinci oxidi 15 or 3 ss 

Amyli 30 Si 

M. et fac chartulam 1. 

Sig. : Use as a dusting powder. 

Or: 



B Olei cadini... 

Petrolati 

M. Sig. : Use externally. 



gm. 

5 
50 


or c.c. 
or 


fl3iss 

5ii 


gm. 

5 
25 
25 


or c.c. 

or 


flSiss 
Si 



Or: 



B Olei cadini 

Adipis 25 

Adipis lanae hydrosi aa 25 

M. Sig. : Use externally. 

Various other forms of tar may be used if desired. 
The following modified Wilkinson's salve is useful : 

gm. or c.c. 
B Sulphuris sublematis 

Olei rusci. aa 

Saponis viridi 

Adipis aa 15 

Cretae praeparatae 5 

M. et ft. ung. 



DIET IN PRURITUS 441 

In preparing this ointment the best oleum rusci 
should be used ; if possible that having the peculiar 
odor of Russia leather. If this cannot be obtained 
either oleum picis or oleum cadinum may be substi- 
tuted for it. 

As a lotion the following antipruritic mixture will 
be found extremely soothing: 



B Zinci oxidi 

Talc 


gm. 

12 

10 


or c.c. 


Sodii biboratis... 


10 




Mentholis 


1 


80 


Glycerini 


6 




Aquae calcis 

M. et ft. lotio. 

Sig. : External use. 


...q. s. ad 180 





Or: 

gm. or c.c. 

ty Tincturae iodi . 51 

Tincturae opii aa 5| or A3 iss 

Glycerini q. s. ad 25 1 A3 i 

M. Sig. : Paint on externally. 

The above prescription may be used when only a 
small part itches, as a chilblain, or something of that 
description. 

Various alcohol and menthol sprays and washes, or 
simple saline sprays are often satisfactory. The fol- 
lowing is a menthol spray : 

gm. or c.c. 

R Mentholis 1 1 gr. xv 

Alcoholis 100| or A3 iii 

Aquam ad 200| flBvi 

M. Sig. : Use externally with an atomizer. 

The question of the use of alcohol and tobacco is 
usually raised in connection with the treatment of pru- 
ritus, and it is generally advised that both should be 
forbidden. Certainly, the vast proportion of people 
who use tobacco and alcohol are not affected with pru- 
ritus. This of course does not indicate that they may 
not be detrimental to sufferers from pruritus, and pos- 
sibly in some instances their use aggravtes the condi- 
tion. In such cases their discontinuance should cer- 
tainly be advised ; but in most cases their use or disuse 
will probably prove to be a matter of indifference. 



442 ETIOLOGY OF PRURITUS ANI 

PRURITUS ANI 
While it is universally insisted that the term "pru- 
ritus" should be strictly limited to such itching affec- 
tions of the skin as are not accompanied by any recog- 
nizable lesion, the term "pruritus ani," on the other 
hand, is used much more broadly, so that under it are 
commonly included such affections about the anus as 
are accompanied by itching but do not show any mani- 
fest lesion, and also those conditions in which there 
are decided pathologic changes in the skin and in which 
intense itching is the most important symptom. Pru- 
ritus ani commands the attention and interest of the 
general practitioner, the proctologist, the dermatologist, 
and, at times, the neurologist. 

ETIOLOGY 

The physician does not do his full duty to his 
patient, if he prescribes for itching about the anus with- 
out making a careful examination of that region and 
interrogating the patient in regard to his habits and 
the manner in which the functions of the different 
organs are performed. It is, ordinarily, a simple mat- 
ter to determine whether the itching is due to the 
presence of the Oxyuris vermicularis (pin-worm) or 
to the presence of pediculi. The occasional occurrence 
of these parasites in this region and their causative rela- 
tion to the production of itching should not be over- 
looked. On local examination, it is frequently possible 
to detect the presence of a fissure of the anus, or an 
ulcer in that situation, or within the sphincter ani mus- 
cle. In other cases there may be found a fistula, hem- 
orrhoids, or polypi ; and further exploration of the rec- 
tum may show a catarrhal condition of the mucous 
membrane, or a disease of the crypts. 

At the beginning of the condition it may be impos- 
sible to find any lesion, but, as the case progresses unre- 
lieved, the energetic scratching in order to relieve the 
itching usually produces a thickening of the skin. 
Inflammation of the skin occurs, causing an increase of 
the connective tissue which presses on the nerve end- 
ings. This may be followed by an atrophic condition 
of the superficial layer of the skin. The thickened 
integument may have a whitish, 'sodden appearance, 



ETIOLOGY OF PRURITUS ANI 443 

and may lie in folds, on or between which there may 
be fissures caused by the scratching. 

Many cases are accompanied by a condition of 
moisture of the skin about the anus. Some believe that 
this moisture is the cause of the itching, but it is more 
probable that in most cases it is an accompaniment of 
the condition that gives rise to the itching, or may 
accompany that lesion of the skin which is produced or 
aggravated by scratching. This moisture is probably 
due to a hypersecretion of the sebaceous glands, but it 
is possible that a part of it comes also from the sweat 
glands. 

In some cases it will be found that a disturbance 
remote from the local manifestation gives rise to the 
itching. Congestion of the mucous membrane of the 
intestine accompanied by a catarrhal condition; con- 
gestion of the liver may be accompanied by a conges- 
tion about the anus which gives rise to intolerable 
itching. Pressure on the veins, as from the enlarged 
uterus during pregnancy, or from pelvic or abdominal 
tumors, may produce similar effects. 

Some general diseases are occasionally accompanied 
by pruritus ani. The most important of these is diabetes, 
but the condition may be present in chronic nephritis, 
in gout, and in rheumatism. It is also a not infrequent 
accompaniment of the degenerative changes which 
accompany old age. Some cases show a decided neu- 
rotic element. Sometimes business or professional 
men who are actively engaged in following their voca- 
tion and who are subject to unusual nervous and mental 
strain are the subjects of this disorder. These various 
conditions, which do not cover all the causes which have 
been enumerated as etiologic factors of this itching, 
indicate that there is a wide scope for the use of 
judgment in selecting a line of treatment appropriate 
for each individual case. When this condition is an 
incident of senility, or of such general diseases as dia- 
betes or nephritis, the treatment is generally palliative, 
by means of local applications. Of course, any 
improvement in the diabetes, or in the nephritis, will 
cause improvement in the local trouble. 



444 TREATMENT OF PRURITUS ANI 

MANAGEMENT 

The dietetic management of the case and the employ- 
ment of such remedies as promote excretion of the 
products of metabolism are clearly indicated. In a 
large number of patients it will be found that a 
rearrangement of the diet is of great importance. 
Many of these patients eat too much, and their diet 
should be restricted so that they eat less and limit the 
amount of food to the needs of the system. In some 
patients who present symptoms which are commonjy 
called lithemic, a limitation of the amount of protein 
ingested, and more especially a reduction of the meat 
to once a day, is advisable. In other patients, it will 
be found that there is a tendency to use an excessive 
amount of sugars and starches, and in such individuals 
these elements of the food should be restricted. 

In many cases there is constipation, accompanied, 
sometimes, by intestinal fermentation. If this consti- 
pation cannot be corrected by a regulation of the diet, 
some laxative may be necessary. Aloes sometimes 
seems to do harm by increasing the irritability and 
congestion about the rectum. Usually cascara sagrada 
or a saline cathartic is preferable. Sometimes it is 
well to give a moderate dose of cascara sagrada at 
night and follow this by a saline laxative in the morn- 
ing, regulating the dose so that the patient may* have 
one soft movement after breakfast. 

If the urine is highly colored, of high specific grav- 
ity, or is strongly acid, the administration of alkalies 
such as potassium citrate is useful. 

Frequently an operation, it may be slight or it may 
be of considerable gravity, is indicated. If there are 
tags of hypertrophied skin, they should be snipped off. 
If there are hemorrhoids, they should be removed. If 
there is a fissure or ulcer, it must be treated by local 
applications of solutions of nitrate of silver daily, if 
the solutions are weak (from 1 to 3 per cent.) ; once in 
four or five days, if strong (10 per cent.). If there 
is a fistula, it should be incised or excised. If there 
is catarrh of the rectum, it may be treated by alkaline 
enemata. 

In a few cases, which persistently resist milder 
forms of treatment, it has been proposed to excise the 



REMEDIES FOR PRURITUS ANI 445 

ring of affected skin surrounding the anus. Some 
favorable results have been reported from this treat- 
ment, but it is generally considered as more severe than 
is necessary. Other surgeons have proposed to incise 
strips of skin, leaving other strips in situ, but passing 
the knife under these so entirely as to separate the 
nerves through which the sensation of itching is trans- 
mitted. 

A considerable number of these patients have been 
treated with very gratifying results with the Roentgen 
ray. These applications may be given at first with two 
exposures a week, until some dermatitis is produced, 
and then once a week. The Roentgen ray causes a 
diminution of the excessive moisture which is some- 
times present, and a decrease in the size of the sebace- 
ous follicles, these seeming to be affected by the ray 
more than the sweat glands. Others have used the 
high-frequency current with asserted advantage. 

LOCAL REMEDIES 

Various local remedies are used with more or less 
success. A group of suggestive prescriptions will be 
found above. Many physicians advise the use of 
cocain, but this should never be given to the patient 
for personal use ; it should only be used by the physi- 
cian to relieve the pain of local applications, such as 
nitrate of silver, or for the performance of minor 
operations. 

Before thinking of applying any remedy, a most 
scrupulous cleanliness should be exercised. After 
every movement of the bowels, the anal region should 
be bathed with hot water, which may be used without 
medication, or there may be dissolved in it simple 
salt, borax, or bicarbonate of sodium. The use of 
newspaper or other coarse paper should be strictly 
prohibited ; indeed, some writers have expressed the 
opinion that the printers' ink on the newspapers is a 
frequent cause of this condition. 

At such times as the itching comes on intensely, espe- 
cially in the evening or after retiring, local applications 
either ice-cold or very hot water often afford consid- 
erable relief. The hot water may be medicated by the 
addition of boric acid to the point of saturation, or with 



446 SCABIES 

borax. Phenol (carbolic acid) may be applied in solu- 
tion of from 2 to 3 per cent, strength, and it may be 
used in much stronger solution once or twice a week. 
A very useful simple application, especially valuable 
in pruritus vulvae, is yeast. It may be applied as brew- 
ers' yeast ; or, as satisfactory, is a solution of an 
ordinary tin-foil-covered yeast cake in a half pint or a 
pint of water. Daily applications of this yeast solution, 
especially at night, will sometimes cure when all else 
has failed. 

PRURITUS VULVAE 

All of the general remarks applicable to pruritus 
ani and perineal pruritus are equally applicable to pru- 
ritus vulvae. Irritating vaginal discharges should be 
ameliorated: the possibility of the presence of insects 
should be considered, and if they are present they 
should be removed. 

Diabetes is a frequent cause of the trouble. Irrita- 
ting, abnormal urine is another frequent cause; when 
this is corrected, or the vulva protected by bland oint- 
ments, the pruritus ceases. In one-sided, unaccount- 
able and unexplainable pruritus, the Roentgen ray has 
effected a cure. 

SCABIES 

If the burrows and the itch mite are found, of course 
the diagnosis of scabies is readily made, but there are 
many cases of itch in which the burrows are difficult 
of discovery, and the itch mite is elusive and evades the 
dermal scrapings for microscopic examination. Even 
the itching varies with different individuals, some few 
being very tolerant of the irritation and thus becom- 
ing conveyors and transmitters of the disease without 
their personal knowledge. 

Various types of skin irritation develop during the 
various stages of scabitic inflammation. There may be 
papules, vesicles, pustules and crusts. The severest 
itching is generally present at night, and especially on 
first retiring. 

"The burrow or run is made by the female in the 
lower layers of the cornified epithelium of the skin." 
These burrows, or "roughened, curved furrows, " occur 
most frequently on the anterior surfaces of the wrists 
and between the fingers. Sometimes these burrows are 



TREATMENT OF SCABIES 447 

simulated by dirt-filled lines in the epidermis. The 
diagnosis can generally then be made by shaving off the 
suspected epidermis with a scalpel, then laying the 
epithelial slice on a slide, adding a drop of glycerin, 
placing a cover glass over it and examining with a 
low power lens. If the eggs of the itch mite, or the 
mite itself, are found, the diagnosis is established. 

When the fingers and hands do not show signs of 
this infection, signs may be discovered on the elbow 
tips, and on the nipples of women. When there is a 
generalization of the disease, characteristic signs and 
eruptions will be seen on the hands, wrists, axillary 
folds, abdomen, nates, in the popliteal spaces, and more 
or less on the genitals. 

It should not be forgotten that the itch may be pres- 
ent in a mixed infection ; in other words, there is more 
or less eczema from the irritations and scratchings, 
there may be nodular and suppurative processes, 
enlarged glands and syphilitic eruptions. 

The disease does not seem to be acquired in ordinary 
social life, but is caught mostly in bed, from individual 
to individual, or by sleeping in an infected bed. 

TREATMENT 

The parasiticides most used in eradicating the itch 
are sulphur, betanaphthol, balsam of Peru and cresol. 

The patient should be instructed to take a hot bath, 
using plenty of soap and thoroughly cleansing, perhaps 
with a soft nail brush, the parts where the parasites are 
mostly located. He should then anoint all parts of his 
body with the sulphur ointment prescribed, and should 
especially rub it into the parts most affected. 

In mild cases of this disease thorough bathing and 
cleansing of the affected parts with strong alkaline 
soap, rubbing and dusting the rest of the body with 
washed sulphur, and then dusting the sheets of the 
bed with this dry sulphur, may cause an eradication of 
the disease without the necessity, discomfort and nasti- 
ness of ointments. 

In more severe cases, sulphur is commonly employed 
as an ointment, 1 to 2 drams to the ounce, thoroughly 
rubbed in over the affected parts, the head alone being 
excepted. The ointment is well rubbed in at night, the 



448 RINGWORM 

patient then donning a suit of woolen underwear which 
is not removed for from three to five nights, the dura- 
tion of the treatment. Each night a new supply of 
ointment is rubbed in. At the end of the treatment 
the patient may bathe, but no bath need be taken 
between treatments. 

SULPHUR 

The official sulphur ointment contains 15 per cent, 
of sulphur, and is stronger than should generally be 
used, on account of the irritation and actual dermatitis 
that it may cause. Either one of the following may be 
preferable : 

gm. or c.c. 

B Sulphuris loti 10 1 or 3 iiss 

Adipis benzoinati. . .q. s. ad. 100| 3 iii 

M. Sig. : Use externally, as directed. 

Or: 

gm. or c.c. 

R Unguenti sulphuris 501 

Adipis benzoinati aa 50 1 or 3 iss 

M. Sig. : Use externally, as directed. 

Or for use especially in children : 

gm. or c.c. 



T£ Sulphuris sublimatis. . . 

Balsami peruvianae aa 2 

Adipis 30 



3 ss 
Si 



RINGWORM: TINEA TRICHOPHYTINA 

To two very different diseases the name "tinea" has 
been given : one is tinea favosa, which is caused by 
the Achorion schonleinii; the other is tinea trichophy- 
tina, which is caused by the vegetable parasitic fungus 
trichophyton. It is the latter to which the present 
remarks will be limited. 

The effects of this fungus are usually divided into 
three subdivisions, according to the particular part of 
the body affected. When that part of the face on 
which the beard grows is affected, it is distinguished 
as tinea barbae, or ringworm of the beard, or barber's 
itch. When the hair of the scalp is affected, it is known 
as tinea tonsurans, or ringworm of the scalp. When 
other parts of the body are affected it is known as 
tinea circinata, or ringworm of the body. These three 



REMEDIES FOR RINGWORM 449 

varieties of the disease are also distinguished respec- 
tively as tinea trichophytina barbae, tinea trichophy- 
tina capitis, and tinea trichophytina corporis. The 
same remedies are applicable to the treatment of these 
three forms of the disease, but the location in which 
the lesion is found necessitates some difference in their 
mode of application. 

The trichophyton fungus is found and grows in the 
epidermal layer of the skin. It penetrates into the 
hair follicles, and also into the root and body of the 
hair. Its presence in the latter locations renders the 
application of drugs for its destruction very difficult, 
and it is on this account that the affection of the hairy 
scalp and the beard is especially resistant to treatment. 

There are several drugs which are useful in the 
treatment of the disease when they can be effectively 
applied. The most important are mercury, hyposul- 
phite of sodium (sodii thiosulphas), tincture of iodin, 
and sulphur. When there are a few spots on the sur- 
face of the body, a useful application is the following : 

gm. or c.c. 

B- • Hydrargyri chloridi corrosivi 10 gr. ii 

Glycerini 5 or fl3 ii 

Aquae ad 50 A3 ii 

M. Sig. : Shake, and rub thoroughly into the lesion, twice 
a day. 

The application of this lotion, or in fact of any 
remedy, should be preceded by a thorough scrubbing 
of the affected parts with hot water and soap, prefer- 
ably soft soap or green soap. When the patient is 
a young child, care should be exercised not to apply too 
strong a lotion and not to apply it to too extensive a 
portion of the body, for too liberal applications of 
strong mercurial lotions may cause mercurial poi- 
soning. 

Another very effective remedy for the trichophyton 
as well as for other vegetable parasitic growths is the 
hyposulphite of sodium. This may be used in the 
strength of 15 to 20 per cent, in water. 

If one prefers to use an ointment — and ointments 
are often exceedingly useful because watery prepara- 
tions do not easily penetrate the skin — an efficient 
ointment is the official unguentum hydrargyri ammo- 



450 ROENTGEN RAY IN RINGWORM 

niati. This ointment is 10 per cent, in strength. If 
there are many spots of disease, or the skin is tender, 
it is well to dilute it with an equal part of lard or 
petroleum fat, as : 

gm. or c.c. 
I£ Unguenti hydrargyri ammoniati 151 

Adipis benzoinati aa 15| or 3 ss 

M. Sig. : Apply to spots twice a day. 

Sulphur may be used in ointment or lotion, but is 
not so efficient. 

If the condition is chronic, and these washes and 
lotions do not prove effective, the patches may be 
painted with tincture of iodin. This may be repeated 
every day for several days until the inflammation 
becomes so great that the application causes objection- 
able discomfort. 

Ointments containing chrysarobin or pyrogallol are 
effective, but should not often be used on account of 
the fact that they stain the skin and clothing, and some- 
times cause considerable inflammation. 

When the scalp is affected and the fungus has pene- 
trated the hair follicles, it is often difficult to apply 
these remedies effectively. It is generally wise to cut 
the hair short, and even to shave the head. The hairs 
will usually be found broken, and it is generally desir- 
able to remove as many of the hairs as possible before 
applying the remedy. The affected parts should then 
be thoroughly washed with soap and water, and lotions 
of corrosive sublimate or of the thiosulphate of sodium 
may be used. 

In cases which prove resistant to other treatment, it 
is sometimes necessary to attempt a cure by producing 
an active inflammation of the affected part. This may 
be accomplished by painting the part with tincture of 
iodin, as has been already mentioned ; or croton oil may 
be rubbed into the affected part; or the part may be 
painted with cantharidated collodion so as to produce 
a blister. This will often result in a rapid cure. 

The Roentgen ray has been used as a germicidal 
application, and as a promotor of a mild dermatitis 
(often a forerunner of a cure) in all parts of the body, 
and with frequent reports of success. The hair, if 



TREATMENT OF RINGWORM 451 

the ray is used on hairy parts, falls out, but seems to 
generally soon return. 

When the beard is affected, the removal of the 
hairs can generally be more thoroughly accomplished, 
and then the various applications already enumerated 
may be used. 

Poultices have been suggested for the purpose of 
softening the skin and cleaning off the crusts, but they 
are generally undesirable, as the moist heat favors the 
growth of the fungus. 

Foley (Lancet, Jan. 24, 1914) describes the follow- 
ing method which he believes is extremely effective : 
The diseased area is first washed with a strong solu- 
tion of sodium bicarbonate and swabbed with spirit 
of ether to remove grease. It is then painted w T ith 
tincture of iodin and sprayed immediately with ethyl 
chlorid until the integument gets china white. The 
deeper the disease process the longer the spray must 
be applied. In ringworm of the scalp three or four 
applications may be necessary, but on smooth surfaces 
one application usually suffices. 

Hartzell has found the ointment suggested by Whit- 
field, which contains 3 per cent, of salicylic acid with 
5 per cent, of benzoic acid, most effective ; but, he says, 
it cannot be used, as Whitfield has pointed out, without 
some degree of caution in markedly inflammatory 
cases, as it occasionally produces considerable irrita- 
tion. 

These cases are often very obstinate, and treatment 
must sometimes be carried on, intermittently, for 
weeks. It often happens that an apparent cure results 
while a few of the fungi still remain in the skin with- 
out showing any evidence of their presence. Conse- 
quently, cases should be kept under observation for 
some time after cure is apparently complete, and if any 
evidence of a return of the disease appears, the treat- 
ment should be renewed. 

This disease appears more frequently in children 
than in adults, and the growth of the fungus seems to 
be favored by high temperature and by moisture. The 
disease is contagious, and is readily passed from one 
individual to another. Where considerable numbers 
of people associate intimately together great care 



452 TINEA TONSURANS 

should be observed to prevent one contracting the dis- 
ease from another. The use of combs, brushes, towels 
and clothing by different individuals should be strictly 
forbidden, especially when the existence of a single 
case among a number of children, as for instance in a 
large family or in a school, is known. It seems likely 
that with the extension of medical inspection to chil- 
dren in the public schools and with sanitary barber 
shops, this disease will, in a few years, become exceed- 
ingly rare. 

TINEA TONSURANS 

Ringworm of the scalp or bearded portions of the 
body is ordinarily a stubborn condition to treat. There 
are two chief methods used in the treatment — the 
drug treatment and the Roentgen ray. 

The Roentgen-ray treatment is of material aid in 
shortening the course of the disease. It produces 
epilation ; it does not seem to kill the fungi but it may 
stimulate the skin to a healthy inflammatory process 
that aids in ridding it of the organisms. Such treat- 
ments should not, however, be undertaken by those not 
thoroughly conversant with the action of Roentgen 
rays, as the harm done by incautious use of the appa- 
ratus may be irremediable. 

Freshwater (Practitioner, 1914, August, xciii, 
No. 2) advises the following adaptation of the older 
method of treating ringworm of the scalp and beard. 
The hair should be cut as short as possible for at 
least two inches around the affected area. A better 
plan is to shave the head all over. The head should be 
washed daily with green soft soap, or an antiseptic 
shampoo wash, such as, 

gm. or c.c. 

R Thymolis 1 1 gr. xv 

Saponis mollis or 

Spt. vini rect ana 30 1 Si 

This is allowed to remain some ten to fifteen min- 
utes on the scalp before rinsing off. The hair around 
the edges of a patch, for at least 1 inch, should be 
pulled out ; this prevents spreading by continuity. A 
good ointment to apply before and during the period 
of epilation, is 



REMEDIES FOR TINEA TONSURANS 453 



gm. or c.c. 

fy Cupri oleatis 4 3 i 

Hydrarg. oleatis 1 66 gr. xxv 

Lanolini 

01. olivae ana 30 S i 

The following prescriptions Freshwater has proved 
to be efficacious, and, he says, if persevered with, will 
ultimately lead to a cure : 



I£ Acid, salicylic 

Sulphur, praecip 2 

Adipis ad 30 

Fiat ung 



gm. or c.c. 

66 



gr. x 
gr. xxx 

Si 



gm. or c.c. 

B Sulphur 4 3 i 

Acid. Salicylic 

Naphthol 

Hydrarg. Ammon ana 66 gr. x 

Lanolini 

Paraffin Liq ana 30 S i 

Fiat ung 

gm. or c.c. 

I£ Sulphur 4 3 i 

Acid. Carboli 2 or 3 ss 

Lanolini 20 3 v 

Paraffin Liq 12 3 in 

Fiat ung 

The following lotions are also serviceable : 



5 



gm. or c.c. 
Liquoris formaldehydi, 40 per 

cent 6| o: 

Aquae 25 1 



Acid. Salicylic 

Spt. Lavand 

Acid. Sulphurous 

Aquae 241 

Acid. Picric 5 

Camphor 1201 

Spt. Vini Rect 180| 



gm. or c.c. 

21 
30 1 or 



3ii 
Si 



a ss 
Si 

3 ii (fresh) 
3 vi 
gr. viii 
3 iv 
Svi 



The lotion should be applied with a brush twice daily 
for a month, when in favorable cases the stumps will 
have fallen. In small chronic patches and in the small 
widely spread patches of a disseminated ringworm, the 
application of croton oil is a valuable form of treat- 



454 TINEA CRURIS 

ment. It is best combined with phenol (carbolic acid) 
or creosote. 

gm. or c.c. 
I£ Phenolis (Acidi Carbol.) • • • llCreosoti gr. xv 
01. Croton 9|01. Croton. 3 ii 

gm. or c.c. 



I£ Acidi Salicylici 

01. Lavandulae 

01. Bergamoti ana 

01. Olivae ad 30 



66 gr. x 

33 or TTt v 
Si 



TINEA CRURIS 

This is a disease that frequently attacks in epi- 
demic form the students of universities and prepara- 
tory schools. It occurs on the inner side of the thighs 
near the body, often spreading to the scrotum, to the 
abdomen, to the perineum, and to the buttocks. The 
hairs do not fall out, thus differing from the ringworm 
that attacks the scalp and other parts of the body. 
There is slight itching and burning, but the disease 
may go on for weeks and even months without very 
much disturbance to the patient. It does not tend to 
recovery, and will persist until properly treated. In 
fact, the treatments outlined by most of the books on 
skin diseases are tediously ineffectual, and the state- 
ment is often made that a cure of the disease requires 
weeks and even months of treatment. Consequently, 
ordinary treatments of this disease are so unsatisfac- 
tory as to be considered of no value. 

The following treatment is one that is always effec- 
tual and always curative in a short space of time. In 
the first place, it must be impressed on the patient that 
reinfection readily and almost persistently occurs 
unless the greatest cleanliness of the underclothing and 
even trousers is inaugurated. Also, it is evidently 
transmitted from patient to patient from the closet 
seats. Dirty jock straps and suspensory bandages used 
in athletics are persistent transmitters of the disease. 
Therefore, clean clothing must be worn after all the 
washable clothing has been boiled and the trousers have 
been properly cleaned and properly ironed. Closets 
must be rendered aseptic by frequent corrosive subli- 
mate baths. 



TREATMENT OF TINEA CRURIS 455 

TREATMENT 

The patient should then be instructed to come to the 
office, bringing clean drawers and a clean shirt, so that 
after the antiseptic treatment he can put on clothing 
that is not infected. The different steps in the anti- 
septic process are : 

1. The parts are all thoroughly cleansed with a soft 
brush or cotton, and liquid soap, and the skin for four 
or five inches distance from the infected areas should 
also be cleansed with this soap. The scrubbing should 
not be very severe, as the skin must not be broken and 
the epidermis not too severely removed. 

2. The infected area should then be wiped over 
thoroughly with a 2.5 per cent, phenol solution. This 
will slightly anesthetize the parts to which the stronger 
antiseptic is to be applied. 

3. A cotton swab is now wet with the official for- 
maldehyd solution. This is then lightly swabbed over 
all the infected parts, which are kept wet for three min- 
utes, provided the patient can stand the burning pain 
for this length of time. If there is an area that is 
especially red and inflamed and sensitive, this part may 
be swabbed with the next solution mentioned before 
the three minutes have elapsed. 

4. The whole area to which the formaldehyd solu- 
tion has been applied is now thoroughly washed with 
the 2.5 per cent, phenol solution. This quickly relieves 
the pain caused by the formaldehyd application. 

5. After the burning pain has ceased, the skin is 
gently dried and talcum powder is dusted over it. The 
patient then dresses in his clean clothing and takes 
care that he does not come in contact with any infected 
garments, beds or closets. 

6. After twenty-four hours the patient should report 
for observation. If severe irritation has been caused 
by the formaldehyd solution, a 2 per cent, phenol oint- 
ment should be applied. If there is not severe irrita- 
tion or inflammation, the simple talcum dusting powder 
is to be freely used. 

7. At the end of a week the patient is again exam- 
ined, and if there are any recurrent small areas, which 
may happen at the margins of the affected region, these 
are again touched with the formaldehyd solution. 



456 IMPETIGO 

By the above treatment a cure may be expected 
immediately and certainly within two weeks. The 
success of the antiseptic treatment is certainly far in 
advance of the ordinary treatments of this inveterate 
disease. 

The preparations advised are as follows : 

gm. or c.c. 

I£ Phenolis liquefacti 2| or 3 ss 

Aquam ad 100| A3 iv 

M. Sig. : 2.5 per cent, carbolic acid solution. 

gm. or c.c. 

1^ Liquoris formaldehydi 100 1 or A3 iv 

M. Sig. : Official formaldehyd solution. 

gm. or c.c. 

I£ Phenolis liquefacti 150 or Tit x 

Petrolati 25 1 Si 

M. Sig. : Apply externally as directed. 

IMPETIGO CONTAGIOSA 

Pus infection of the skin, usually of the staphylo- 
coccic type, is an exceedingly troublesome condition. 
Ammoniated mercury ointment is usually recommended 
for this condition. The official ointment contains 10 
parts of white precipitate in 90 parts of benzoinated 
lard. Sutton has stated that this preparation is too 
strong for the most effective use and he finds an oily 
preparation better than a fatty preparation, viz. : 

gm. or c.c. 

R Hvdrargyri ammoniati ll or gr. xv 

Olei olivae 100| AS iv 

M. Sig. : Shake well and apply freely several times a day. 

If deemed advisable, compresses may be soaked in 
this solution and kept in place over the affected areas 
by means of bandages or adhesive plaster. In the 
hairy parts of the body, as in the beard, a continuous 
application for twenty-four hours of the above solu- 
tion will loosen all crusts and allow the antiseptic to 
reach the germs of infection and will inhibit the spread- 
ing of the disease. Sutton finds such treatment ren- 
ders a cure possible in a week, whereby with other 
treatments from two to four weeks are needed. 



PSORIASIS 457 

Unna (Berl. Klin. Wchnschr., 1915, Hi, p. 453) 
says : "No true pus coccus affection of the skin, no 
isolated furuncle, no felon, should be taken lightly. 
When any of these have lasted any time, true pus cocci 
are already installed in the neighboring apparently 
sound hair follicles, ready to start new impetigo or 
furuncles. They must be walled off from the rest of 
the skin with a rampart of coccus-destroying sub- 
stances. " For this he uses ichthyol, or an ichthyol or 
mercury-phenol plaster, or a zinc-sulphur-chalk-turpen- 
tine paste. Another formula contains 10 parts sulphur 
latum, 10 parts calcium carbonate and 80 parts zinc 
ointment. 

Before applying any of these preparations he washes 
the lesions and after drying touches them lightly with 
concentrated phenol on the suppurating points and 
also the roots of the hair around the spot. In case of 
extensive pyodermia, all the pustules are opened and 
the entire body is rubbed long and thoroughly with 
soap. He states any soap will do except tar soap, 
which, he thinks, breeds folliculitis. All the pustules, 
then, and their environment, are covered with zinc 
paste and gauze as maceration of the skin from friction 
of any kind promotes spreading of the impetigo. 

PSORIASIS 

The cause of psoriasis has been variously attributed 
to an infectious nature, to errors in metabolism, to dis- 
ease of the glands of internal secretion. 

Spiethoff (Med. Klimk., 1914, Nov. 8, x, p. 1664) 
in a discussion of various theories in regard to the 
origin of psoriasis, says that it is doubtful if any of 
them have conclusive weight. An inherited tendency 
seems evident in 5 or 6 per cent, of the cases, and any- 
thing causing internal disturbances is liable to aggra- 
vate the condition or bring on attacks, especially diges- 
tive disturbances, abuse of coffee, tobacco or alcohol, 
a diet too rich in albumin, or constitutional disease. 
When diabetes and glycosuria can be excluded, benefit 
is often derived from a vegetarian diet. 

TREATMENT 

In treating psoriasis, as has been mentioned, a vege- 
tarian diet often yields marked improvement. As to 



458 GENERAL TREATMENT OF PSORIASIS 

symptomatic measures, Spiethoff does not rank any 
very high except Roentgen exposures. These are 
peculiarly effectual in the old cases with tough infiltra- 
tions on the limbs and head. Among the internal 
remedies he thinks that arsenic seems to be the only 
one that is worth mentioning; he has never seen any 
effect from salvarsan. Patients with severe psoriasis, 
taking a course of salvarsan for syphilis, did not find 
that the medication had any influence on the psoriasis. 
Serotherapy is inconstant in its action, but he extols the 
benefit from venesection in cases with much itching. 
Withdrawing from 50 to 100 c.c. of blood, repeating 
this two days later, generally put an end to the itching 
in his experience with it. 

Arsenic may be given in the form of Fowler's solu- 
tion, three to ten minims, three times a day or as 
arsenous acid in pills. The Asiatic pill is frequently 
prescribed as follows: 

gm. or c.c. 

fy Arseni trioxidi 25 gr. iv 

Piperis 2 50 or gr. xl 

Pulveris gentianae compositi.. 
Glycerini aa q. s. 

M. et fac pilulas 100. 

Sig. : Commence with one pill before each meal, and 
increase one pill every second day until the full physiologic 
effect is secured. Then decrease one pill a day every second 
day. 

Arsenic should not be given when the eruption is 
active and increasing. When it has been given to 
full physiologic effect, as evidenced by pain in the 
stomach, nausea, vomiting, diarrhea, puffiness or red- 
ness of the eyes, albumin or blood in the urine, it 
should be stopped for a day or two. 

The salicylates, alkalies and diuretics have also been 
recommended for internal use in psoriasis in some 
cases. 

Recently the autogenous serum treatment of psoria- 
sis has been highly advocated in this country by Gott- 
heil of New York, and Fox, Ravogli and Willock have 
published reports showing almost complete failures 
with this method. However, in any condition as diffi- 
cult of eradication as psoriasis, methods which have 
seemed to yield success in the hands of even a few 



LOCAL TREATMENT OF PSORIASIS 459 

specialists may be worthy of trial. In this method 
from 80 to 100 c.c. of blood are withdrawn, usually 
from a vein at the bend of the elbow, and centrifuged 
as soon as it has clotted. From 25 to 45 c.c. are 
obtained in this way and immediately reinjected intra- 
venously into the patient. The time taken by the pro- 
cedure varies from three quarters of an hour to two 
hours. The procedure may be repeated several times 
over a fairly long" period, 

LOCAL TREATMENT 

The scales may be removed by scraping with a sharp 
curet and washing with hot water and green soap. 
A stiff brush may be used. If the scales are hard and 
there is thickening a 5 per cent, salicylic acid ointment 
will aid in softening and removing them. 

Chrysarobin is the remedy of chief reliance in remov- 
ing the patches. It may be given in the following 
manner : 

gm. or c.c. 

ty Chrysarobini 1 1 or gr. xv 

Liquoris guttae perchae (N. F.) 10 1 3 iii 

M. Sig. : Apply at night, with a camel's hair brush. 
Or: 

gm. or c.c. 

R Chrysarobini 3 1 3 i 

Aetheris or 

Alcoholis q. s. ad solutionem 

Collodii 25| Si 

M. Sig. : Apply at night with a camel's hair brush. 

Chrysarobin should not be used on the face and it 
should be remembered that the stains which it makes 
on clothing cannot be removed. 

An ointment containing chrysarobin and salicylic 
acid (Dreuw's ointment) may be used over small areas 
on severely indurated lesions. The formula is : 

gm. or c.c. 

fy Acidi salicylici 10 3 iii 

Chrysarobini 20 

Olei rusci aa 20 or 3 vi 

(Oil of Birchwood) 

Saponis mollis 25 

Petrolati aa 25 Si 

M. Sig. : "Rub in well, with a stiff brush, for five evenings. 
Then take hot baths on three successive evenings, using appli- 
cations of olive oil in the meantime (to soften the skin). 
Repeat if necessary." 



460 BOILS 

"When there are patches of psoriasis on the face or 
scalp only the white precipitate ointment should be 
used, as the chrysarobin is likely to give rise to severe 
erythema and edema in these regions." 

It is best not to persist too long with any one remedy. 
Ammoniated mercury ointment, 5 to 10 per cent., may 
be of value, and ichthyol, tar, sulphur and beta-naph- 
thol have likewise formed the chief ingredients of 
curative ointments. 

BOILS (FURUNCLES) 

The boil is usually a staphylococcic infection of the 
skin, beginning around a hair follicle, following an 
abrasion of the skin through friction from clothing, 
or otherwise. There seems to be no doubt that general 
furunculosis is associated with a lowering of the indi- 
vidual resistance to infection. Unna has described 
several ointments to be used in preventing the spread 
of these staphylococcal infections. These have been 
noted under the heading Impetigo. 

The boil may sometimes be aborted by injecting into 
it, before it has pointed, a drop or two of a 5 to 10 
per cent, solution of phenol, or by just touching its 
surface with 95 per cent, phenol and then covering 
the boil and the surrounding area with ichthyol oint- 
ment or a 5 to 10 per cent, salicylic acid ointment. 

A 10 per cent, salicylic acid ointment may be made 
as follows : 

gm. or ex. 

B Acidi salicylici 5| 3 iss 

Unguenti 50 1 or 3 ii 

M. Sig. : Use externally as directed. 

Schitle (Dent. nied. Wchnschr., 1915, xl, p. 2023) 
declares that every furuncle can be aborted in the first 
forty-eight hours if the center is burnt out under local 
anesthesia with 2 per cent, novocain injected first to 
make a blister and then injected perpendicularly into 
the center of the boil. The actual cautery can then 
be used to burn out the center or merely a knitting 
needle can be used, heated red hot in an alcohol flame. 
The knitting needle can be stuck through a cork for a 
handle. To prevent further furuncles developing the 
skin should be cleansed with soap, rubbed with alcohol 



ALOPECIA 461 

and any suspicious looking points painted with tinc- 
ture of iodin, burning out the center if a furuncle does 
develop. Even with a fully developed furuncle he 
advocates burning out the center plug in this way rather 
than to incise. The hyperemia thus induced aids in 
warding off new infection. 

The above treatment is perhaps somewhat radical. 
The following has also been advised: The inflamed 
part should be thoroughly scrubbed with soap and 
water, then washed off with 50 per cent, alcohol, and 
then an alcohol compress should be applied to the 
part and allowed to remain until the alcohol has 
evaporated. The region is then again washed with 
soap and water and the suds allowed to dry on, no 
other dressing being applied. If there is no pus, a 
single treatment is said to abort the furuncle. 

If the boil has already pointed, it should be evacu- 
ated, ordinarily by a crucial incision down through the 
plug. Anesthesia may be obtained by spraying with 
ether or ethyl chlorid. Carbuncles should be cut out 
entire under general anesthesia. The skin in the 
region of the boil should be washed with hydrogen 
peroxid or with mercuric chlorid solution (1 : 1,000 or 
1 : 2,000) and then a cloth covered with 5 per cent, 
salicylic acid ointment may be applied. 

Autogenous vaccines have been much used when 
furuncles recur repeatedly or in crops. There seems to 
be sufficient warrant for their use with good hope of 
preventing recurrences. 

Needless to state, the recurrence of furuncles should 
be a signal to make thorough examination of the urine 
as to the presence of sugar, indicating diabetes. 

ALOPECIA : BALDNESS 

Several different forms of this condition have been 
described, of which the following are the types : 

Alopecia congenitalia is an exceedingly rare condi- 
tion in which a child is born without any hair. Micro- 
scopic examination of the skin in some cases shows an 
entire absence of follicles. In other cases the follicles 
are present, and after weeks, months, or possibly two 
or three years, the hair grows, although it is usually 
finer and thinner than in the average child of the 
same age. 



462 PREMATURE BALDNESS 

Another variety is alopecia senilis, in which the loss 
of hair is an accompaniment and an indication of the 
general atrophy of the tissues throughout the entire 
body. 

There is the disease called alopecia areata, which is 
characterized by a complete falling of hair from limited 
areas of the scalp or other hairy portion of the body. 
This is a distinct disease, and will not be considered in 
this connection. 

There remains the form of alopecia prematura, in 
which the patient loses more or less of the hair to which 
he has become accustomed, but in which this loss is not 
associated with the changes characteristic of old age. 
This form of premature baldness is customarily divided 
into two classes : the idiopathic and symptomatic. In 
the idiopathic form few causes can be found for the 
occurrence, while in the symptomatic form there will be 
found some pathologic condition of the scalp, or some 
disease which has affected the general nutrition of the 
entire body. Under the latter head may be included 
the falling of the hair which so frequently follows 
typhoid fever, and which has recently been discussed 
at some length in this department. Omitting at the 
present time a discussion of the other forms of 
alopecia, a few words will be said regarding the com- 
mon form of premature alopecia. 

The most that can be said of premature baldness, 
according to The Journal of the American Medical 
Association (March 20, 1915, p. 1018), is that it is 
senile baldness coming on before the usual time. Of 
its causes we know actually nothing. We do, however, 
know the sequence of events. 

Between the skin of the scalp and the skull there is a 
thick layer of fat to which the skin is loosely attached 
and on which it is freely movable. In civilized man, 
who lives in houses and wears hats, the following 
changes take place as he approaches later life : This fat 
layer gets thinner; the scalp becomes more firmly 
attached to the skull and less movable ; the skin 
becomes more tense, and with these changes the hair 
becomes thinner and thinner over the top of the head. 
Finally, in extreme cases, the hair disappears and there 
is left a bald, glistening crown closely drawn over the 



SENILE BALDNESS 463 

skull. This sad picture is senile, spontaneous or sim- 
ple baldness. Premature baldness is the same thing, 
only occurring before the age when these changes, 
which we ordinarily attribute to old age, are expected 
to appear. 

What is the process that has taken place here? 
There has been a disappearance in great part of the 
subcutaneous fat; the scalp has become much more 
dense in structure — has become fibrous or sclerotic 
— and with this shrinking in the scalp there has been 
a gradual shrinkage in the hair follicles until they 
entirely disappear, and are replaced by fibrous tissue. 
It is a process much like that taking place in many of 
the tissues in later life, and in some of the organs often 
as a result of disease. It resembles closely, for exam- 
ple, the destruction of the epithelial tubules in the kid- 
neys that takes place as a result of chronic inflamma- 
tory processes. And it is a process that can readily be 
explained as a result of a chronic inflammatory process 
in the scalp. This is a reason for one view that all 
so-called senile baldness is really due to dandruff or 
seborrheic dermatitis. The sounder view seems to be 
that the change may be simply one of senile atrophy 
occurring as a primary process and not secondary to 
any diseased condition of the scalp. 

The explanation of the fact that baldness is usually 
confined to the top of the head probably is that the 
increased tension of the scalp resulting from its shrink- 
age exerts its chief pressure on the top of the head. If 
one pulled a bag tightly down over the head it would 
exert much more pressure on the top of the head than 
around the border. 

Simple or senile baldness, in spite of its name, usually 
begins to manifest itself early. The thinning of the 
hair becomes apparent before the age of 30 in 80 per 
cent of the cases, and persons who are not nearly bald 
at 50 are likely to keep a passable covering of hair 
until they reach old age. 

The definite causes of simple baldness are uncertain, 
and there is much room for speculation. As a result, 
all sorts of factors are invoked to explain it, from the 
wearing of tight hats to improper methods of breathing. 
Some would go so far as to say that there is no such 



464 BALDNESS IN MEN AND WOMEN 

thing and to attribute all of the cases to seborrheic 
dermatitis. This is an extreme view ; but certainly the 
ravages of dandruff have to be taken into account in 
all cases of baldness, and in considering the causes of 
the condition, no separation can be made between sim- 
ple baldness and that due to dandruff. 

Baldness is much commoner in men than in women. 
This is true, however, only of complete baldness ; thin- 
ning of the hair as a result of nervousness and other 
depressing influences on the health is commoner, per- 
haps, in women than in men. The reasons for the 
occurrence of baldness less frequently in women than 
in men are probably various. In the first place, women 
give much more attention to the toilet of the hair — 
to brushing it, and keeping it clean and in good con- 
dition; their hats are light things that merely rest 
on the hair, and finally, the fat layer of the scalp, as 
of the skin generally, is more abundant in women than 
in men and atrophies later in life. Man sometimes is 
inclined to have it that baldness is a sign of intelligence 
and a result of mental labor and that that is the reason 
it is commoner in men. This fiction is one of the few 
consolations that can be urged for the condition, and it 
seems mean to disturb it, but, truth to tell, there is no 
ground for it. Baldness may make one look wiser, but 
it occurs indifferently in the great and small, and it is 
no more a sign of wisdom than long hair is of genius. 

The broad fact seems to be that in the common 
occurrence of baldness we have a manifestation of 
a transitional stage in man's evolution. The hair on 
the body now is the vestige of a former abundant coat. 
In the economy of nature, structures atrophy and dis- 
appear when they cease to have function, and the need 
of warmth and other protection afforded by the hair 
is no longer of great importance to man. Man now 
uses a hat instead of relying for protection for his head 
on a shock of hair as his ancestors did, and, as a result, 
in spite of all his coaxing, the shock of hair is gradu- 
ally vanishing. This does not mean that you and I can 
save our hair by discarding our hats. We are result 
of our ancestors, and to save our hair we would have 
to discard the hats of all our ancestors for scores of 
generations back. 



PREVENTION OF BALDNESS 465 

According to this view, heredity is one of the great 
causes of baldness, and all statistics indicate that this 
is true. In the statistics of Jackson and of White, the 
condition is due to heredity in from 30 to 40 per cent, 
of the cases. 

Mistreatment of the hair is also an important factor 
in the production of baldness. Daily wetting of the 
hair, especially if no attention is given to drying it, 
keeping it poor in oil by excessive use of soap and 
water without supplying any fat in place of that 
removed, failure to keep it clean, excessive exposure 
to sunlight, the indiscriminate use of drugs, particu- 
larly "hair tonics," and overzealous treatment by 
barbers and hairdressers — all of these causes are 
influential in the production of baldness, and are to be 
guarded against, particularly in the care of hair of 
those who have already a predisposition to the con- 
dition. 

The effects of heavy and tight hats by interfering 
with the circulation of the scalp is considered to be of 
great importance, and there can be little doubt that it is 
a factor to be considered. Hats should be light. They 
should provide for circulation of air, and should not 
bind the head. It can at least be said for women's hats 
that usually they are better in these respects than 
men's. 

But after ail other factors have been considered, we 
must still come back to seborrheic dermatitis — dan- 
druff — as the most important cause, and the one to 
which most care must be given in preventing baldness. 
According to White's statistics, it is a factor, and per- 
haps the chief factor, in 79 per cent, of the cases ; 
according to Jackson's, in 72 per cent., and according 
to Elliot's in 91 per cent. 

PROPHYLAXIS 

It is apparently little considered by the average indi- 
vidual that the hair should receive as particular care 
as do the teeth and nails. To be sure, it is the custom 
of most people to comb their hair, but this is generally 
done for the cosmetic rather than for hygienic effect. 
By improper care of the hair great harm may be done, 
and conversely, people who desire to preserve their 



466 SHAMPOO 

hair in good condition should take pains to encourage 
its healthy growth. Many people overdo the matter 
of making applications to the scalp, applying strong 
alcoholic preparations or other so-called tonics too fre- 
quently. Others, with an excess of pains, bathe it too 
frequently, especially with cold water, as is the case 
with people who take a daily cold shower bath. Others 
indulge too frequently in the luxury of a shampoo. 
While occasional washing of the hair is beneficial, too 
frequent application of water to the hair does harm by 
withdrawing the natural oil from the hair and scalp. 
The best authorities advise shampooing the scalp not 
more frequently than once a week and not less fre- 
quently than once a month. Probably nothing better 
can be used on these occasions than Castile soap and 
w r arm water. 

With women, the case is somewhat different, but 
they have their special unhygienic practices which must 
be mentioned and condemned, especially the curling of 
the hair by winding it about hot curling-irons or doing 
it up in curl-papers over night. 

In women, if hair is found to be cracking at the 
ends and becoming thin and unhealthy, the ends should 
be cut off. 

The popular remedies to prevent falling of the hair 
would fill an encyclopedia. Vibratory and electrical 
treatments, hair tonics that feed the hair roots, as 
though they grew out of the scalp like broom-sedge out 
of an old field, neat's-foot oil and crude kerosene, mas- 
sage and mange cures, all have their futile trials. 
Among them must also be included a method highly 
recommended by many barbers and beauty specialists, 
namely, singeing the hair. This is recommended to 
overcome splitting at the ends and to prevent falling 
of the hair, the reason for the latter being that it 
"closes the pores and keeps the fluid in the hair." With 
the long hair of a woman which has a tendency to split 
at the ends, it is possible that singeing the tips may be 
of some use; it substitutes a charred blunt end of 
fused horn for one tapering to a point or cut clean 
across. But even in cases of this sort it is less useful 
than greasing lightly the hair and thus supplying the 
fat which is lacking in such hair. For the hair of 



■^ 



TREATMENT OF ALOPECIA 467 

men, which is kept short, singeing is not of any use 
in preventing the splitting ; hair which is not allowed to 
grow to its natural length does not split, unless it has 
a deep-seated disturbance for which there is no such 
simple remedy. Of course singeing the hair-ends in 
order to prevent the fluid in the hair from escaping, 
like sap from a tree, is based on an entire misconcep- 
tion of the hair's structure and nutrition. The hair 
does not contain any more sap than a buggy whip ; it 
is not nourished by any fluid in it, but by the blood 
plasma that reaches only the hair root. The hair above 
the skin surface is a spine of horn, which is even oiled 
from without, and singeing its tips has no effect what- 
ever on either its nourishment or its growth. It is 
certain that singeing the hair is of no value in pre- 
venting its fall; in fact the only value the procedure 
has is to the zealous hairdresser who gets his little fee 
for doing it — unless it is worth a quarter to the seeker 
after hair to think he is doing something, even if he 
is not. 

TREATMENT 

The treatment of baldness, whether due to a local 
inflammation of the scalp or to the result of some 
general disturbance of nutrition, is a somewhat puz- 
zling matter. The treatment adopted must be con- 
tinued for several weeks or even months before a 
result of much importance can be observed. Obviously 
at first the constitutional condition of the patient should 
be carefully inquired into, and any disturbance of it 
should be promptly remedied. If care and worry are 
apparently important factors in the disease, these 
should be remedied as far as possible. If the digestion 
is not properly performed, measures should be adopted 
which will correct it. 

Certain internal remedies have appeared to have 
some control over the nutrition of the skin and scalp. 
Perhaps none surpasses arsenic in this respect, and in 
many cases the use of this drug will seem to contribute 
to a favorable result. If anemia is present, iron may 
be combined with arsenic. For instance : 

gm. or c.c. 

I£ Arseni trioxidi |04 gr. J<£ 

Massae ferri carbonatis 2| or 3 ss 

M. et fac pilulas 20. 

Sig. : Take one pill, three times a day, after meals. 



468 LOCAL APPLICATIONS FOR DANDRUFF 

Another drug which has appeared to have a selective 
action on the skin and scalp is sulphur, and in some 
cases this drug has been given with benefit, especially 
if there is constipation, or if there is observed a ten- 
dency to suppurative inflammation of the skin. 

The question of local applications to the scalp is 
one which must be approached with some hesitation. 
The variety of drugs which have been recommended 
for application to the scalp to stimulate the growth of 
the hair is so great that one naturally feels suspicious 
in regard to the value of any one. This, however, 
must not discourage the physician from trying to select 
a suitable one which will prove of benefit to his patient. 
If dandruff is abundant on the scalp, one of the sim- 
plest applications is a solution of borax, with glycerin 
and water. 

gm. or c.c. 

I£ Sodii boratis 4| 3 i 

Glvcerini 25 1 or fl3v 

Aquam ad 200| A3 vi 

M. Sig. : Shake, and apply externally twice a day. 

This, like all applications designed for use on the 
scalp or for the purpose of stimulating the growth of 
the hair, should be applied to the scalp and not to the 
hair. This may be accomplished by using a comb to 
part the hair, separating it so that the application may 
be made directly to the scalp, and when the application 
has been made along one part, making successive appli- 
cations along other parts, until the application has been 
made over the entire scalp. 

Another remedy which has been extensively used 
for the relief of dandruff is resorcin. This may be 
used in the form of either a lotion or an ointment. 

I£ Resorcinolis 

Alcoholis 

Aquam ad 

M. Sig. : Shake and apply to the scalp twice a day. 

Or: 

gm. or c.c. 

R Resorcinol 150 gr. x 

Adipis lanae hydrosi 25 1 or Si 

M. Sig. : Rub into the scalp twice a day. 



gm. or c.c. 




6 




3 iss 


75 


or 


flSiii 


200 




flSviii 



LOCAL APPLICATIONS FOR DANDRUFF 469 

These remedies are especially useful when there is 
any evidence of inflammatory action in the scalp 
because of their soothing and anti-inflammatory action. 
In these cases remedies which are stimulating should 
be avoided. If there is no evident pathologic process 
going on in the skin except the falling of the hair, 
more stimulating remedies may be applied. Of these 
the most important are alcohol, quinin, cantharides, 
and ammonia. These, with resorcin, which has been 
already mentioned, are the fundamental ingredients of 
most popular hair tonics. Bay rum, a favorite appli- 
cation to the hair with many people, owes its pleasant 
effect largely to the alcohol contained in it. 

The tincture of cantharides is often combined with 
alcohol and castor oil as in the following prescription : 

gm. or c.c. 

Yz Tincturae cantharidis 10 1 A3 iii 

Olei ricini 5| or A3 iss 

Alcoholis q. s. ad 100| A3 iv 

M. Sig. : Apply externally. 

When corrosive sublimate is used the proper strength 
is half a grain to an ounce (0.03 gm. to 30 c.c.) of 
alcohol. 

Ammonia may be used, as in the following prescrip- 
tion of Erasmus Wilson : 

gm. or c.c. 
fy Aquae ammoniae fortioris.. 10 

Chloroformi 10 

Olei amygdalae expressi..aa 10 or A3 iii 

Olei limonis 3 A3 i 

Alcoholis q. s. ad 100 A3 iv 

M. Sig. : Apply by dabbing on the scalp with a small piece 
of cloth, but not with friction. 

The hydrochlorid of pilocarpin may be used in the 
form of an. ointment : 

R Pilocarpini hydrochloridi 

Olei lavendulae 

Petrolati 

Adipis lanae hydrosi 

M. Sig. : Use externally. 

A sulphur ointment may sometimes be used with 
advantage. 



gm. or c.c. 




1 




gr. xv 


1 


or 


TTlxv 


10 




3 iii 


30 




%\ 



470 LOCAL APPLICATIONS FOR DANDRUFF 

Dore (Clin. Jour., 1914, xliii, No. 3) believes that 
in seborrheic cases, resorcin, salicylic acid, mercuric 
chlorid, sulphur and tar are the best drugs. In the 
majority of cases he uses a lotion such as the fol- 
lowing : 

gm. or c.c. 
I£ Hydrarg. chloridi corrosivi. . 03 — .12 gr. ss — ij 

Resorcini vel acidi salicylici.. 30 — .60 gr. v — x 

Olei lavand 06 — .12 Tfi, i — ij 

Olei ricini vel glycerini 30 — .60 TTL v — x 

Spt. vini rect ad 30 3j 

If the scalp is dry the castor oil may be increased 
in quantity; if excessively greasy a solvent of fat such 
as ether or acetone may be added. 

A spirit lotion is, he states, the best dressing for the 
hair of women ; in men, water or weak spirit with 
glycerin instead of castor oil is sometimes preferable. 
Resorcin discolors white or very fair hair and salicylic 
acid should then be substituted. In severe cases an 
ointment may be required at first and may be rubbed 
in every night and washed off in the morning, or a 
small quantity applied once or twice a week after 
shampooing, that is : 

gm. or c.c. 

$ Naphthol P.. 

Sulph. praecip 

Resorcini 

01. lavand 

Vaselini ad 30 



30— .60 gr. v— x 

60— 1.20 gr. x— xx 

60— 1.20 gr. x— xx 

06— .12 111 i— ij 



Sj 

To this oil of cade, etc., may be added. 

When seborrhea is not a marked feature, as in toxic 
and nervous cases, pilocarpin may be substituted for 
the mercuric chlorid in the first prescription or pre- 
scribed with ammonia or other stimulant, that is : 

R Pilocarpini nitrat 

Liq. amnion, fort 

Tinct. lavand. comp 

Spt. vini rect 

Aquam ad 

This lotion is also effective in slight degrees of 
seborrhea, because the ammonia forms a soap with the 
fat of the scalp. Other useful stimulants are chloral 
hydrate, acetic acid and cantharides ; the last should 
be used with caution on account of its action on the 



gm. or c.c. 






30 


gr. v 


4 




3j 


4 




3j 


50 




5ii 


200 




3 viii 



URTICARIA 471 

kidneys. Internal medication should not be forgotten, 
especially in neurotic and anemic cases and the glycero- 
phosphates, cod-liver oil, iron, strychnin and arsenic 
are of service. 

URTICARIA 

The causes of simple urticaria are food (protein) 
poisoning, intestinal parasites, poisoning by certain 
drugs, disturbances of the liver or kidneys, gout, con- 
ditions associated with an increased amount of uric 
acid in the urine, constipation, an abnormally dry skin, 
and, in fact, anything that impedes normal elimination. 
Circulatory disturbances, especially when combined 
with high blood-pressure or arteriosclerosis, may be 
factors in causing urticarial eruptions. 

Urticaria may occur, however, from almost any 
feverish condition or from any infection, and simply 
becomes, then, an added symptom. Most frequently 
urticaria is the most important symptom, and from its 
intense itching is the cause of the patient seeking 
medical advice. 

The following treatment of simple urticaria has been 
suggested, namely, catharsis, a limited milk or cereal 
diet, large amounts of water, the administration of 
alkalies, such as potassium citrate in 2 gm. (30 grain) 
doses, given four or five times in twenty-four hours, 
or some other alkali, if preferred. Potassium citrate 
may be given as follows : 

gm. or c.c. 

B Potassii citratis 501 or 3 ii 

Aquae gaultheriae 200| AS viii 

M. Sig. : Two teaspoonfuls, in water, every four hours. 

If it is known that the stomach and intestines 
have been irritated, bismuth subcarbonate and sodium 
bicarbonate should be administered, and, if the. patient 
does not quickly recover, some form of calcium. 

The patient should be kept cool. Thin and non- 
irritating underwear should be used. If the patient is 
a child or one in whom the condition tends to recur, 
linen or silk underwear should be worn. Warm baths, 
the water made alkaline with sodium bicarbonate, are 
soothing to urticarial patients, and will relieve the itch- 
ing. The skin should not be rubbed, but should be 
mopped, lest the drying process cause irritation and 



472 TREATMENT OF URTICARIA 

more itching. The localized spots may be sprayed with 
alcohol, cologne, or even mild acid applications, such 
as vinegar. Phenol solutions have long been used to 
dull the irritability of the peripheral nerves; a 2 
per cent, solution, with or without glycerin often 
suffices, as : 

gm. or c.c. 

I£ Phenolis liquefacti 4| 3i 

Glycerini 25 1 or AS i 

Aquae menthae piperitae 

q. s. ad 200| A3 viii 

M. Sig. : Use externally as a lotion. 

[The preceding should be well shaken and should be 
labeled as poison.] 

Sometimes such applications as "extract of witch- 
hazel" or a bland oil like almond oil will be soothing 
to the irritated skin. If the urticarial spots are not in 
large numbers, such application as camphor or chloral, 
with or without menthol, are often valuable, as : 

gm. or c.c. 

R Camphorae 

Chlorali hydrati . . / aa 2| or 3 ss 

Glycerini 25 1 AS i 

Alcoholis q. s. ad 100] AS iv 

M. Sig.: Use externally. [Shake, and label as poison.] 

gm. or c.c. 

I£ Camphorae 

Chlorali hydrati aa 2| 3 ss 

Mentholis 1| or gr. xv 

Glycerini 25] fl§ i 

Alcoholis q. s. ad 100 1 . AS iv 

M. Sig.: Use externally. [Shake, and label as poison.] 

Various dusting powders are often of benefit, espe- 
cially in children suffering from this condition. The 
simplest is powdered starch or a talcum powder. Some- 
times stearate of zinc, with or without menthol, is of 
value as tending to adhere to the region that is irritated. 

When urticaria continues or recurs, as it does occa- 
sionally in its milder forms, the whole physical condi- 
tion, diet and personal hygiene, of the patient must be 
very carefully investigated. Some wrong condition 
will be found and when it is corrected the disturbance 
will disappear. Especially must the intestinal digestion 
be studied. If constipation or indigestion is present 



ROENTGEN DERMATITIS 473 

measures to prevent the absorption of the irritants will 
generally cure the urticaria. Occasionally in young or 
older persons in whom a high tension or arteriosclero- 
sis has begun or who have insufficient kidneys, condi- 
tions of the skin exist that cause temporary reddening, 
and perhaps itching, with the least irritation. 

The skin may be so hypersensitive as to allow of 
what is termed "dermographia." This condition is a 
pseudo-urticaria, and the treatments that tend to relieve 
urticaria will generally relieve this condition. 

When there are angioneurotic edemas, a diminution 
of the sodium chlorid in the food will often be a valua- 
able adjunct to the other treatment inaugurated. This 
is especially true if the kidneys are at all insufficient. 

Giant urticaria, on the other hand, is a serious, 
dangerous affection, especially if it attacks the face and 
mouth, as, when present, it is likely to do at any 
moment, and dangerous swelling in the throat and 
larynx may occur. This condition should be treated 
energetically, and the patient should be under close 
observation. 

The treatment of giant urticaria is catharsis with 
calomel and saline cathartics ; a milk diet, if milk agrees 
with the patient ; or a plain water diet ; or a cereal diet. 
Calcium should be given, and alkalies in large doses. 
Occasionally, large doses of quinin, such as 60 eg. (10 
grains) tw T ice a day, or good-sized doses of antipyrin, 
as 1 gm. (15 grains) three times a day, have seemed 
almost specific. Atropin pushed to physiologic action 
is sometimes of value. The exact cause of this serious 
condition has not been determined. Doubtless, how- 
ever, it is anaphylactic and due to protein poisoning. 

ROENTGEN DERMATITIS 

The wide use of the Roentgen ray in the treatment 
of various diseases has led to the occurrence of Roent- 
gen burns with dermatitis and severe rapidly growing 
new growths. 

Caldwell, Abbe and others are convinced that the 
most practical, easiest applied treatment is the use of 
radium. The application of radium is free from pain 
and under its influence the lesions seem to retrogress. 
The effectiveness of the freezing methods and of the 



474 ECZEMA OF PALMS AND SOLES 

electric-spark methods cannot be questioned, but they 
are both painful. Sparks can sometimes be applied in 
situations impossible to reach with liquid air or carbon- 
dioxid snow. Of the two methods, freezing is some- 
what less painful. The value of surgery in such cases 
has been demonstrated beyond any shadow of doubt, 
but these operations are dangerous and they call for 
exceptional surgical judgment and technical skill. 
Under the best conditions excision cannot be safely 
done ordinarily without sacrificing healthy tissue. The 
possibility of hastening metastasis must always be con- 
sidered. 

Dodd has found the following application simple 
and efficacious in the treatment of the ordinary acute 
reaction following Roentgen-ray exposure : 

gm. or ex. 

fy Zinci oxidi 251 Si 

Phenolis 2| or 3 ss 

Glycerini 4| 3 i 

Aquae calcis 200| 3 vtii 

Shake well and bathe area for five to ten minutes, 
twice or three times a day. Avoid all heavy dressings 
and, when possible, expose the lesion to the air. Do 
not apply this remedy on a dressing, and allow to 
remain for five to ten minutes, but sap it on and let the 
air get to the lesion. Under no conditions, he believes, 
should an ointment be used. 

HYPERKERATOTIC ECZEMA OF PALMS 
AND SOLES 

This type of eczema follows exposure of the 
hands to injurious influences such as rough weather, 
water, cleansing agents, chemical solutions and various 
traumatisms, and the encasing of the feet in ill-fitting 
and deforming shoes, which produce callosities and 
breaking down of the arch, thereby increasing sweat- 
ing of the soles and resulting in maceration of the 
keratotic, thick epithelium. In no other type of chronic 
eczema is local treatment more efficacious and more 
satisfactory, says Montgomery and Culver (Jour. 
Cut. Dis., 19.15, xxxiii, No. 5), than in hyperkeratotic 
eczema of the palms and soks. 



TREATMENT OF ECZEMA 475 

Locally a plaster mull may be employed, containing 
5 per cent, salicylic acid in soap plaster : 

B Acidi salicylici 5 per cent. 

Emplastri saponis (Beiersdorf) 95 per cent. 

This is applied on the fingers and covered with zinc 
oxid adhesive plaster, so as to intensify its action. 
This is changed once in twenty-four hours. Under its 
use the hard, concrete-like hyperkeratosis of the fingers 
melt down, and the skin becomes smooth and supple. 
This plaster cannot be applied to the feet as it would 
crumple up in walking, but an ointment may be pre- 
pared of about 12 per cent, salicylic acid in equal parts 
of lanolin and petrolatum, as follows : 

gm. or c.c. 

R Acidi salicylici 8| or 3 ii 

Lanolini 

Petrolati aa 32 1 Si 

This is applied in the morning, so that in walking it 
will be massaged into the skin. A few days later, when 
the patient is able to resume work, an ointment com- 
posed of one part of mercury in ninety-nine parts of 
simple ointment is used. 

gm. or c.c. 

Ffc Hydrarg. salicylatis II or gr. xv 

Ung. simplicis 99 1 3 iv 

A salve composed of 6 per cent, each of red oxid of 
mercury and camphor and 12 per cent, of white lead, 
in an ointment base composed of equal parts of lanolin 
and petrolatum, may be used as follows : 

gm. or c.c. 

fy Hydrarg. oxidi rubri 

Camphorae aa 4 3 i 

Plumbi carbonatis 4 or 5'i 

Lanolini 

Petrolati aa 32 Si 

M. Sig. : Well rubbed in, twice a day. 

In one case cited by Montgomery and Culver, after 
five weeks the daily applications were changed from 
the above to a lotion consisting of : 



476 TREATMENT OF ECZEMA 

gm. or c.c. 

R Kali caustic 1|5 gr. xx 

Glycerini 50 1 or 3 ii 

Spts. vini rect 501 S ii 

Aquae rosae q. s. ad 150 1 3 vi 

M. Sig. : Local use, twice a day, before using a salve; and 
a salve consisting of : 

gm. or c.c. 

fy Hydrarg. salicylatis \3 gr. v 

Paraffin 5 1 or 3 iss 

Petrolatum alb 25 1 Si ' 

M. Sig. : Rub in twice a day. 

Another patient sought treatment on account of a 
hyperkeratotic eczema of the fingers and right palm. 
He also had hyperidrosis, accompanied with light red 
erythema of both palms. A lotion was prescribed, con- 
sisting of : 

gm. or c.c. 

I£ Liq. plumbi subacetatis 16| or 3 v 

Liq. carbonis detergentis 80 1 5 iii 

M. Sig.: Two teaspoonfuls in pint of hot. water as a lotion 
and apply as compresses for ten minutes, twice a 
day. 

There was also prescribed an ointment: 

gm. or c.c. 

I£ Ichthyoli 16 gr. xxv 

Hydrarg. oxidi rubri 4 5i 

Camphorae 4 or 3 i 

Plumbi carbonatis 8 3 ii 

Lanolini 

Petrolati aa 32 Si 

M. Sig. : Rub well into the lesions twice a day, after soak- 
ing the hands in the lotion. 

Some time after this, the liquor carbonis detergens 
was painted on in the full strength once a day, and the 
above dilute lotion of liquor carbonate detergens and 
lead water was used only once a day, in the evening. 
The ointment was changed to one of : 

gm. or c.c. 

I£ Emplastri, plumbi | 

Petrolati aa 30 1 or 3 i 

Liq. cresol. com 1|2 gr. xx 

M. Sig. : Use on fingers twice a day. 

Six weeks after beginning treatment his lesions had 
all disappeared. In a number of instances in which 



CHAPPED HANDS 477 

other applications have failed, resorcin, in less than 4 
per cent, strength, has been found excellent. 



gm. or c.c. 



3 ss 
3 ss 
5 or 3 ii 
5 gr. xx 



B Resorcini . . .« 2 

Glycerini 2 

Zinci oxidi 7 

Cerae albae 1 

Adipis benzoatis 50 

Dissolve the resorcin in heated glycerin. Melt together the 

wax and the lard, and add, while constantly stirring, 

the dissolved resorcin and the well-triturated oxid of 

zinc. Sig. : Rub in well, twice a day. 

The official unguentum acidi borici often acts well; 
the white precipitate in 2 to 4 per cent, strength in an 
ointment, may, in some instances, be better than the 
salicylate of mercury as given in one of the above pre- 
scriptions. Some of the best results in treating eczema 
of the soles, and especially of the palms, have been 
obtained by Montgomery and Culver by the use of 
Roentgen rays, after all other lines of treatment have 
failed, for months or even years. 

CHAPPED HANDS 

The chief reason for chapping of the hands is the 
lack of fat in the skin in cold weather. Fat produc- 
tion in the skin is at a minimum in cold weather, 
because of the diminished sebaceous and sweat secre- 
tion. This and the dry air of winter make the skin 
dry and vulnerable at the very time when the cold air 
is itself irritating. This combination leads readily to 
chapping, if the hands must be exposed much to soap 
and water, and particularly if the irritation of antisep- 
tics is added, as in the case of physicians and nurses. 

The first thing to do to prevent or overcome the con- 
dition is to supply, by greasing the skin occasionally, 
the lacking fat in the skin. Almost any bland fat or 
semisolid hydrocarbon will do for this purpose, but 
nothing is better than a well-made cold cream. The 
next and more difficult thing to do is to avoid soap and 
water — especially soap — as much as possible ; and 
it is here that hand lotions serve a very useful purpose. 

Hand lotions are generally of two types: (1) 
glycerin solutions of the glycerin, rose water and ben- 
zoin kind, and (2) gelatinous liquids made with traga- 



478 CHILBLAIN 

canth, quince seed, or some other water-soluble colloid. 
The glycerin lotions work well with some skins and 
are the most satisfactory to an occasional individual, 
but as a rule they are not the best, first, because the 
glycerin tends to make drier a skin already too dry, 
and, second, because these lotions have little or no 
detergent effect and do not clean the skin. 

The tragacanth and quince seed lotions are better, 
and of these the tragacanth lotions are certainly as 
good as any other and are very cheap and easy to make. 
A formula for such a lotion given by Pusey is as fol- 
lows : 

gm. or c.c. 

I£ Tragacanth 5 3 iss 

Glycerin 16 3 v 

Boric acid 16 or 3v 

Water q. s. 1000 Oi 

Oil of bergamot n\ iv 

Oil of lavender TTt ii 

Oil of rose TTt i 

The oils mentioned being added as a perfume might 
be omitted, one or all of them, according to the wish 
of the prescriber. 

The boric acid, glycerin and waters are first mixed, 
the tragacanth added and the mixture agitated until 
the tragacanth is dissolved. This makes a rather thick 
mucilage ; it can be changed to any consistency desired 
by slight increase 6v decrease in the amount of traga- 
canth. 

A lotion like this has a considerable detergent effect ; 
it is a tolerable substitute for soap, and if it is freely 
rubbed over the hands and wiped off, either with or 
without the use of water, cleans the skin of all but the 
most tenacious dirt. It, of course, cannot be effectu- 
ally used as a complete substitute for soap. Such a 
lotion has the advantage over soap that it not only is 
not irritating to sensitive skin but also is bland and 
soothing. It thus tends to prevent and eventually to 
cure chapping of the hands. 

CHILBLAIN 

The conditions favoring chilblain are impaired and * 
weak circulation. Hence it is seen chiefly in the lower ™ 
extremities, especially in the feet, but may affect also 



TREATMENT OF CHILBLAIN 479 

the fingers, ears, nose and cheeks, parts especially 
exposed to the cold. 

The principal manifestations of the disorder are a 
burning heat, with itching and redness. These symp- 
toms are usually worse at night. 

Rapid change of temperature or prolonged exposure 
to cold, and especially to cold combined with dampness 
and moisture, undoubtedly produces slight histologic 
changes, of an inflammatory character, in the cutaneous 
structures. These have been designated by some writ- 
ers as chronic erythematous dermatitis. 

Relief is sometimes obtained by painting the affected 
part with tincture of iodin, or with equal parts of tinc- 
ture of iodin and tincture of opium. Oil of peppermint 
diluted with from one to six parts of glycerin has been 
recommended as affording relief. 

F. Gardiner of Edinburgh (Practitioner, Febru- 
ary, 1908), recommends ichthyol, which may be used 
in the form of a 10 or 20 per cent, ointment with 
lanolin (adeps lanae hydrosus). This should be 
spread thickly on linen, and applied for several succes- 
sive nights. It relieves the congestion, inflammation, 
burning and itching. He has also used with benefit the 
faradic and high-frequency currents of the Roentgen 
ray. 

If the chilblain undergoes ulceration, the same 
author recommends the following ointment : 

B Hydrargyri ammoniati 

Ichthyol (ammonii sulpho- 
ichthyolatis) 

Amyli 

Zinci oxidi aa 

Petrolati 15 

M. Sig. : Spread on linen and apply to part. 

When the inflammation proves resistant to treatment, 
the possibility that the affection is something more 
serious than chilblain, perhaps either lupus erythema- 
tosus or Reynaud's disease, must be considered. 

C. Ritter (Munch, med. Wchnschr., May 7, 1907) 
reports 150 cases treated by Bier's method of artificial 
hyperemia. He finds that this acts best in acute cases 



gm. 


or c.c. 






30 


gr. v 




60 


Ttl. x 


8 


or 




8 




3 ii 


15 




3 ss 



480 FROSTBITE 

and in chronic cases occurring in fairly healthy per- 
sons. The action is always beneficial. 

Hot air he finds to be most useful when the condition 
is of long standing. 

The following simple combinations may be of benefit 
for chilblains, painful corns or bunions : 

gm. or c.c. 

R Tincturae opii 

Tincturae iodi aa 15| or flS ss 

M. Sig. : Paint once daily over the painful part. 

gm. or c.c. 

fy Mentholis 1 gr. xv 

Methylis salicylatis 8 or 3 ii 

Adipis lanae hydrosi 25 3 vi 

M. Sig. : Apply a small quantity frequently, rubbing in 
until absorbed. 

gm. or c.c. 

I£ Camphorae 1 150 gr. xx 

Balsami peruviani |50 gr. vii 

Olei amygdalae dulcis 10 1 or 3 i i i 

Adipis lanae hydrosi 

Aquae rosae aa 25 1 Si 

M. Sig. : Use externally. 

FROSTBITE 

If chilblain is regarded as a chronic affection gen- 
erally due to the action of cold, frostbite may be 
regarded as an acute affection due to the action of cold. 
When a portion of the body not properly protected is 
exposed to intense or extreme cold the tissues become 
affected, and if the cold is sufficiently intense and the 
exposure is sufficiently prolonged the part becomes 
frozen. Individuals in whom the circulation is weak, 
and particularly the young, the old and the debilitated, 
are especially likely to suffer from intense cold. Like- 
wise those parts in which the circulation is least active, 
and which are least protected by clothing, as the ears, 
hands and feet, are prone to suffer. 

Different degrees of frostbite are recognized. In the 
slighter forms, the smaller arteries become contracted, 
the circulation becomes slow, and there is venous 
stasis. This is accompanied by a change in the various 
structures, and also in the blood contained in the ves- 
sels of the affected part. 



TREATMENT OF FROSTBITE 481 

If the cold is more intense or the exposure is more 
prolonged, vesicles and blisters or blebs, containing 
often sanguinolent fluid, form. 

Finally, if the exposure is sufficiently severe and 
sufficiently prolonged, the entire part becomes con- 
gealed, and freezing and gangrene result. 

Locally the part becomes cold, pale, or bluish, 
shrunken or wrinkled, and there is loss of sensation 
and diminution, or entire loss, of the power of motion. 

Constitutional symptoms vary with the condition of 
the individual and the extent of the lesion. Loss of 
energy, fatigue and weakness are early symptoms. 
These may be followed by indisposition to continued 
exertion, difficulty of speech, delirium, coma, and 
death. 

Mayo Robson (Lancet, Jan. 16, 1915, p. 118) 
emphasizes chiefly that in the treatment of frost-bite 
it is of the utmost importance to save as much of the 
injured extremities as possible, and as it is impossible 
to say how much of the damaged tissues will survive, 
immediate or early amputation is absolutely contraindi- 
cated. The best treatment at first is friction with snow 
or cold water in a cold room, the changes to a warmer 
atmosphere being gradually brought about. Frictions 
with turpentine and oil or with spirit and soap liniment 
are useful remedies in the early stage, and after the 
friction the limbs should be raised on pillows and 
swathed in cotton-wool, which can be held in position 
by bandages applied loosely so as to avoid any danger 
of constriction. If blisters form, or discoloration of 
the toes or other parts shows that gangrene is prob- 
able, the whole foot should be sterilized by rubbing 
with oil of turpentine to cleanse the skin or with spirit 
containing 1 in 500 biniodid of mercury, after which 
strips of sterilized double cyanid gauze should be 
applied between the toes and the same gauze made to 
cover the whole foot, which is then enveloped in ster- 
ilized cotton-wool. Any blisters — which will be found 
to contain dark blood stained fluid — should be snipped 
and carefully dried and dressed with the spirit and 
biniodid lotion. Painting with tincture of iodin would 
probably be quite as effectual, as an antiseptic, as the 
spirit and biniodid solution. 



482 LICHEN PLANUS 

Every effort should be made to keep the parts dry 
and sterile, and if gangrene occurs the surgeon should 
on no account make too great haste to amputate, as 
the tissues adjoining the line of demarcation become 
more and more healthy and the line of granulation tis- 
sue between the dead and living tissues, if kept asep- 
tic, gives rise to little discharge and can be kept aseptic 
by a daily dressing with the spirit solution. Ultimately, 
when it is seen what flaps of skin are available, the 
dry, shrivelled gangrenous parts can be removed and 
the bones severed at such points as will allow the flaps 
to be conveniently applied to make a good cover to 
die stump. Cases in which the gangrenous process 
has only involved the superficial layers of the skin, the 
separation of the necrosed part should be left to 
Nature and afterward skin grafting will be found use- 
ful. If as a result of neglect or the use of wet dress- 
ings the gangrene has assumed the moist variety and 
the wounds are infected, the spirit dressings will still 
be useful, and the foot should be well dusted with 
equal parts of zinc oxid and boric acid, so as to make 
every effort to convert the moist into dry necrosis, and 
thus to avoid general septic complications and the 
danger of the gangrene spreading. 

LICHEN PLANUS 

R. L. Sutton (Jour. A. M. A., 1914, Jan. 17, lviv, 
p. 175) describes certain variant forms of lichen 
planus which might escape recognition by the prac- 
titioner. He also includes in his consideration certain 
conditions heretofore included in the lichen group, but 
which have little clinical and no histologic resemblance 
to the typical form. Probably the most frequent of 
the aberrant types are those with circular patches of 
closely grouped more or less typical papules. Much . 
rarer are the annular forms from gradual extension 
from single large papules. A form rather common, 
in England but rare elsewhere is the linear type, the 
lichen planus striatus of Crocker, in which a narrow 
fillet of the eruption often follows the course of the 
sciatic nerve. Sutton thinks the most plausible 
explanation of this type is that it is due to scratching 
or other linear injury of the skin and not to nervous 



TREATMENT OF LICHEN PLANUS 483 

disturbance. The vesicular and bullous types of the 
disease are rare, but two cases are reported by Sutton, 
as is also a case of a type followed by atrophy. Other 
atypical types are the warty type, lichen planus hyper- 
trophicus, lichen chronicus simplex (Vidal), which 
Sutton agrees with Brocq and Jacquet is a circum- 
scribed pruritus with subsequent lichenification. It is 
one of the conditions mentioned as not being one of 
true lichen planus. The name prurigo nodularis has 
been given as a name for this condition and will prob- 
ably be generally adopted. 

In the treatment, besides the regular hygienic and 
nutritional measures, Sutton has found mercury, as 
originally recommended by Liveing, greatly superior 
to arsenic. It is best given intramuscularly in the glu- 
teal region and the soluble form rather than the insolu- 
ble form is preferred. In the hypertrophic form it 
may be alternated about once in two weeks with arsenic, 
or, better, with arsenic and iron. Alkaline diuretics 
are often beneficial, but he has found salicylates worse 
than useless on account of the gastric irritation. Cool- 
ing antipruritic ointments which are also more or less 
curative, and a soothing, non-greasy application which 
the patient may use at will, are advisable. A cooling, 
antipruritic ointment, which is at the same time more 
or less curative, may be made as follows : 

gm. or c.c. 

$ Phenol 15 Tl\. v-x 

Menthol 5 gr. y-x 

Ammoniated mercurial ointment 10 1 or 3 jii 

Zinc oxid ointment 10 3 iii 

Anhydrous wool-fat 20 1 3vi 

Lime water, sufficient to saturate. 
Make into an ointment. Apply freely two or three times 
daily. 

In addition to an ointment, it is advisable to pre- 
scribe a soothing, non-greasy application which the 
patient may apply at will. One of the best is ordinary 
calamine lotion, to which has been added from 1 to 
10 per cent, of Duhring's coal tar preparation : 



484 VACCINES IN SKIN DISEASES 

gm. or c.c. 

I£ Phenol 1 n\xv 

Compound tincture of coal- 
tar (Duhring) 5 3 Hi 

Zinc Oxid 

Starch or 

Powdered calamine aa 20 3 vi 

Glycerin 10 3 Hi 

Water, sufficient to make... 125 3 vi 

Mix. Shake and apply freely several times daily. 

This mixture is as hot as it is efficient, but Sutton 
found it of value in many intensely pruritic conditions. 

For the eradication of the thick, scaly patches in 
lichen planus hypertrophicus, numerous methods have 
been suggested, none of which are entirely satisfactory. 
Repeated freezing with Pusey's carbon dioxid snow 
often is beneficial, and Roentgen therapy in an 
erythema dose (one sufficient to give rise to an erythe- 
matous reaction) or less, constitutes a reliable aid. 
The long-continued application, under rubber or oiled 
silk, of ointments containing considerable percentages 
of salicylic acid and tar occasionally results in a cure. 

No efficient plan for treatment of prurigo nodu- 
laris has yet been devised. For the relief of the itching 
Sutton finds Bronson's oil (phenol and solution potas- 
sium hydroxid, of each \y 2 dram, linseed oil 1 ounce) 
serviceable, although destruction of the lesions by 
repeated deep freezing with carbon dioxid snow, he 
believes, is probably the best plan. 

VACCINE THERAPY IN SKIN DISEASES 

Gilchrist {Jour. Cut. Dis., 1913, December, xxxi, 
p. 975) summarizes his experience with vaccine 
therapy in over 800 cases of cutaneous disease. His 
brilliant results, failures and average successes assumed 
equal proportions. He believes that whenever an 
organism can be obtained in pure culture from a case 
of skin disease, it is only proper that an autogenous 
vaccine should be used, especially if it is chronic or 
subacute; or, when the disease is acute, and it does 
not yield to the usual modes of treatment and becomes 
dangerous. It is still necessary to pay careful atten- 
tion to diet, to the regular functions of the body, to 
other internal and external treatments, as well as the 



VACCINES IN SKIN DISEASES 485 

application of Roentgen rays in some cases. Many 
infectious diseases of the skin do not require vaccines 
at all, as, for example, impetigo contagiosa, in which 
in the very large majority of the cases, local applica- 
tions cause the lesions to disappear in a few days. 
Vaccines are of the greatest value in chronic or sub- 
acute and especially relapsing staphylococcic affections 
of the skin, where there is a lack of production of anti- 
bodies. Vaccines are of great value in the treatment of 
relapsing furunculosis, sycosis vulgaris, pustular der- 
matitis and folliculitis. 

In the various forms of eczema the results vary, and 
Gilchrist says that if a case of pustular, weeping or 
vesicular eczema is chronic, or relapses, and does not 
yield rapidly to the usual treatment, then vaccines 
should be tried. In rosacea the treatment yielded some 
very marked results. In connection with acne vul- 
garis, vaccine therapy has proved to be of great value 
in the treatment. As the result of his experience in 
the treatment of about 400 cases of acne, Gilchrist 
finds that a stock bacillus acne vaccine made in the 
hospital laboratory is as efficacious as an autogenous 
one. Gilchrist has also used ointments made up with 
various skin organisms successfully. It appears as if 
a localized immunity was produced by the application 
of such ointments. The use of a filtrate from living 
organisms was tried with some success in three cases 
of blastomycosis. Filtrates from the staphylococci 
were also used in staphylococcic affections, but not 
with beneficial results. 

Kreuscher (///. Med. Jour., 1913, xxiv, December) 
reports good results from autogenous vaccine therapy 
in a number of cases of acne, furunculosis and car- 
bunculosis. 

More recently Wolfsohn (Mitteil. a. d. Grenzgeb. 
Med. et Chir., 1914, xxvii, No. 1) has discussed the 
results of seven years' experience with this method. 
He believes that even the greatest skeptics must be 
convinced of the beneficial results in certain conditions. 
Still better results may be anticipated when the vac- 
cine therapy is supplemented by other therapeutic 
methods, especially chemotherapy, and when the 
desired clinical reaction is realized with the least dan- 



486 BORIC ACID IN SKIN DISEASES 

gers by utilizing vaccines made with the least possible 
injury of the antigen elements. He has applied vac- 
cine therapy in thirty-four acne patients, and nine were 
not influenced in the least; nine were temporarily 
improved, and sixteen were completely cured of their 
long rebellious acne. No benefit was apparent in his 
twelve cases of postoperative osteomyelitis fistula, 
nor in six of mastitis, but his success in six cases of 
furunculosis in infants justifies further trials with 
small doses. Vaccine therapy to date has been applied 
in about 2,000 cases of furunculosis in adults, but the 
published records do not state whether the trouble was 
old and chronic in all the cases, while this alone calls 
for vaccine therapy. In his thirty-two cases the furun- 
culosis had lasted from two to twenty years, and twelve 
of the patients were completely and twelve others 
partly cured. In eight others no influence from perse- 
vering vaccine therapy was apparent. The cure has 
persisted from one to three years to date. A poly- 
valent vaccine often proved effectual but autogenous 
vaccines were more reliable. 

In only three of his fourteen cases of chronic eczema 
was a cure realized, and nine were entirely uninflu- 
enced. His success surpassed all expectations in six 
cases of obstinate sinusitis in the accessory cavities 
of the nose. General streptococcus infection is less 
promising for vaccine therapy, and the treatment failed 
completely in his eight cases of erysipelas of the face 
and in four other points, but in two cases of erysipelas 
of the arm distinct benefit was apparent. Acute strep- 
tococcus affections contraindicate vaccine therapy, but 
it may help in the subacute and chronic cases, espe- 
cially with scarlatinal complications and migrating 
erysipelas. 

BORIC ACID IN SKIN DISEASES 
Boric acid, according to Montgomery {Jour. 
A. M. A., 1915, lxiv, p. 883), has a very extensive use 
in skin diseases but is almost always used as an adju- 
vant. 

Acne. — An initiatory soaking with a hot boric acid 
solution is often of great benefit in the local treatment 
of acne. For this purpose it is desirable to apply the 



BORIC ACID IN SKIN DISEASES 487 

solution hot and to use a large quantity of it, so that 
the heat will be retained for a considerable time. Three 
heaping tablespoonfuls of boric acid powder are added 
to the usual quantity of water used in washing — 
about 3 quarts. This makes approximately a 3 per 
cent solution. The patient should then sit, leaning over 
the bowl, and soak the face well with towels wrung out 
of the hot solution. As the solution grows cooler, 
more hot water may be added. It is often advan- 
tageous so to soak the face for ten or fifteen minutes. 
It softens the epithelium and acts as an excellent deter- 
gent, removing the grease and many of the micro- 
organisms, and decidedly increases the efficiency of a 
resorcin or sulphur application. 

Furuncle. — In the primary stage of active congestion 
in furuncles, Montgomery suggests that moist heat 
together with a nonirritating antiseptic are the topical 
therapeutic indications. These indications, he says, 
may be met by employing gauze dipped in hot satu- 
rated (4 per cent.) solution of boric acid, and envel- 
oping with oil silk to retain the moisture and the heat. 
This is similar to a poultice, but is not so good, as it 
is not so bland and does not retain the heat so well; 
it, however, is often sufficient, and is easier to apply. 
An admirable poultice for this purpose is made by 
mixing boric acid powder with starch paste. The 
preparation of this will be taken up later. 

Styes. — The stye is a form of furuncle of the eye- 
lid. It has been pointed out that styes may be related 
to seborrhea of the scalp. In the treatment of styes, 
Montgomery orders persistent bathing and soaking for 
half an hour twice a day with warm saturated solution 
of boric acid, and after each soaking to rub in a salve 
of 1 per cent, red mercuric oxid in vaselin. 

Suppurative folliculitis of the vibrissae of the nares 
is another pyogenic affection in which boric acid may 
be employed with advantage. This folliculitis is a 
most tantalizing affection, and is often combined with 
cracking of the mucous membrane at the anterior angle 
of the nares, constituting one of the causes of red 
nose. These lesions may also furnish a convenient 
entrance for the streptococci. An efficient manner of 
treating this folliculitis is to set before the patient a 



488 BORIC ACID IN SKIN DISEASES 

tin cup of saturated solution of boric acid, kept hot 
by placing it over the flame of a spirit lamp. The 
patient takes pledgets of absorbent cotton, dips them 
in the hot solution, and pushes them into the affected 
nostril, repeating this during ten or fifteen minutes till 
the tissues are well softened, and the crusts softened 
and loosened. Calomel, 12 per cent., or xeroform, 12 
per cent, in vaselin, is then well rubbed in. This pro- 
cedure may be repeated two or three times a day. 
Care must be taken both to soak thoroughly and 
anoint the fossae behind the nose tip, as these hollows 
are a favorite residence for germs in this affection. 
Epilation may or may not be necessary. 

Impetigo. — To remove the crusts in impetigo Mont- 
gomery applies to the lesions a boric acid starch poul- 
tice. The making of this poultice is a simple matter, 
but it is often the simple matters that are the most 
neglected. It is made in the following manner : 

Take ordinary, common, lump, laundry starch and 
pulverize it. This pulverization is to be done before 
measuring. Dissolve one slightly heaping tablespoon- 
ful of the pulverized starch in two tablespoonfuls of 
cold water. Add to this one coffee cupful of boiling 
water, stirring rapidly until the mixture is a thick 
paste. To this paste add a tablespoonful of boric acid, 
free from lumps, and stir well until thoroughly mixed. 
Fold the warm jelly between layers of thin muslin or 
cheesecloth, and apply as hot as can be borne. 

A good poultice should not be too thin or it will 
dry, nor too bulky, or it will run ; it should be slightly 
less than a finger thick. In order to prevent the bor- 
ders drying and sticking to the surface, they may be 
greased with vaselin, oil or zinc oxid ointment. 

This poultice is not gummy like a linseed poultice, 
is cleaner looking and retains heat just as well. 
Besides the foregoing use, such a poultice has a multi- 
tude of applications, sometimes being employed hot, 
sometimes cold, as pointed out by Sabouraud. 

When, by means of this poultice, the crusts are 
softened and loosened, they may be gently removed. 
This removal is often best accomplished by rubbing 
in a salve containing an appropriate antiseptic, such 



BORIC ACID IN SKIN DISEASES 489 

as ammoniated mercury. The following ointment is 
an excellent one for the purpose : 

gm. or c.c. 
B Ung. hydrargyri ammoniati.. 15| 3 ss 

Ung. zinci oxidi 30| Si 

M. Sig. : Use twice a day both to clean and dress the 
affected surface. 

The real efficient antiseptic in the above is the 
ammoniated mercury, a remedy familiar to every skin 
clinic in which naturally streptococcic infections are 
among the daily visitors. The 10 per cent, ointment 
of the Pharmacopeia, however, is too stimulating, and 
the zinc oxid ointment both dilutes it and modifies its 
asperity. 

As a general lotion for more widespread use in very 
scattered pyogenic infection of the skin, a saturated 
solution of boric acid in dilute alcohol serves admir- 
ably. It is harmless, it is clean and does not stain, 
and is not disagreeable in either appearance or odor, 
and because of the alcohol cutting the fat of the 
cutaneous surface, both the alcohol and the boric acid 
are permitted to act effectively as antiseptics. 

Perleche. — In this infection of the mouths of infants, 
pledgets of cotton wet in warm boric solution should 
first be industriously sopped into the corners of the 
mouth where there is cracking and a characteristic 
grey veil-like covering. If possible, they should be 
drawn across the corners of the mouth saddlewise and 
left there. After this, the ointment of ammoniated 
mercury and zinc oxid above mentioned, should be 
rubbed in. 

Paronychia. — In paronychia or felon, both as an 
abortive measure, and as an antiphlogistic antiseptic 
measure, a dressing of a combination of boric acid and 
liquor alumini acetici may do excellent service. A 
lotion is made of : 

gm. or c.c. 

I£ Liq. alumini acetici 30 1 Si 

Acid boric sol. sat 300| A3 x 

M. Sig. : Employ warm water to bathe the finger, and also 
as a wet dressing. 

Gauze soaked in this solution is wrapped about the 
finger, and then an amply fitting rubber finger -stall is 
drawn over it and retained by a not too tight bandage. 



490 PICRIC ACID IN SKIN DISEASES 

Liquor alumini acetici is among the best of the mild 
antiseptics, and is gradually coming into favor in sur- 
gical clinics. It must be carefully prepared, and should 
be diluted about ten times. The water employed in 
its dilution is not an indifferent matter, as that con- 
taining carbonates throws down a heavy gelatinous 
precipitate of aluminum hydroxid. As the foregoing 
prescription is put up by a druggist, and with distilled 
water, this mischance is avoided. 

Montgomery believes that used either alone or com- 
bined with other powders, boric, acid is very valuable 
in many discharging diseases of the skin. An excel- 
lent powder is made of equal parts of boric acid and 
talc, or of equal parts of starch, zinc oxid and boric 
acid. 

The boric acid ointment of the Pharmacopeia con- 
tains about 8 per cent, of boric acid, while Lister's 
ointment is much stronger — about 16 per cent. Boric 
acid ointment is an excellent nonirritating preparation 
with a multitude of uses. It is an ointment that, more 
generally than any other, is well prepared, and this is 
a point of importance when the druggist who is to put 
up a prescription is not known, as ointments are often 
wretchedly made. In seborrheic conditions this oint- 
ment will sometimes agree when those more usually 
employed fail. 

PICRIC ACID IN SKIN DISEASES 

Wilcox (Archives of Pediatrics, 1913, xxx, p. 877) 
believes that as an aid in the relief of discomfort in 
skin lesions as well as in their cure, picric acid has 
proved its worth. The drug is safe and easy to han- 
dle, the only drawback being the permanent staining 
of everything with which it comes in contact. 

Eczema. — Better results were obtained in the acute 
than in the chronic eczemas ; most striking was the 
improvement seen in the acute cases having profuse 
exudation, excoriation and crusting. In the milder 
cases an aqueous solution painted on several times 
daily and allowed to dry was used, while in the more 
severe cases wet dressings of picric acid were applied, 
held in place by a facial mask. Lessening of the itch- 
ing and pain attendant on the inflammatory condition 



PICRIC ACID IN SKIN DISEASES 491 

was almost immediate. Reduction in the serous exu- 
dation and softening of the crusts were equally prompt. 
Improvement in the induration was rapid, as was the 
subsequent epithelialization. Such a rapid relief of the 
suffering attendant on this distressing condition was 
not obtained by any other means. Picric acid alone 
was not as efficacious in the subacute and chronic 
types of the disease; it was found, however, that the 
curing of the lesions was hastened materially by treat- 
ment initiated by two or three days' application of the 
picric acid solution. The effectiveness of the usual 
ointments, containing zinc, tar, salicylic acid, calomel, 
mercury, etc., was much greater than without this 
preliminary treatment. 

Intertrigo. — Intertrigo was treated with picric acid. 
The solution was painted on the surfaces of the skin 
involved and they were kept from coming in contact 
by thin layers of absorbent cotton. In the more 
severely infected cases wet dressings were used. Cures 
were effected in about half the time taken on similar 
cases treated with ichthyol solutions. The use of pic- 
ric acid in intertrigo was so satisfactory that a bottle 
of the aqueous solution is now part of the regular 
equipment of the dressing carriage, and the nurses, in 
the routine of changing the babies' napkins, apply it 
whenever the buttocks appear red or irritated. 

Erysipelas. — Results in the treatment of erysipelas 
were not uniformly successful. In certain ways they 
were, however, more satisfactory than the results 
obtained by the use of any other method. The dis- 
comfort and pain attendant on the condition were 
relieved more quickly and the edema disappeared 
rapidly. In several cases, desquamation in cast-like 
masses followed the use of picric acid, leaving a 
healthy normal skin beneath. A reduction in the tem- 
perature of these patients was the rule, occurring with 
or without marked improvement in the local condition. 

Herpes Labialis. — In herpes labialis a more rapid dry- 
ing up of the lesion and fewer extensions of the 
trouble were obtained with picric acid than with any 
other method used. With the exception of immediate 
and constant relief from the itching, children suffer- 
ing from psoriasis showed no particular response to 



492 BURNS 

the treatment. In impetigo, better results were 
obtained with the use of antiseptic ointments than with 
picric acid washes. Picric acid ointments were not 
used on these cases. 

TREATMENT OF PERSPIRING FEET 

Excessive perspiration of the feet, while not an 
important ailment is one concerning which the physi- 
cian is frequently consulted because of its persistent 
and disagreeable nature. 

In the treatment of this condition the cautious use 
of the Roentgen ray is recommended as the best 
method of checking excessive perspiration. Among 
the local applications which may be used with benefit 
are tannic acid, alum or zinc sulphate in from 1 to 8 
per cent, solutions (from 1 dram to 1 ounce to a pint of 
water), Another useful application is a 1 per cent, 
dilution of liquor formaldehydi in water. The parts 
should be washed and then bathed in one of these solu- 
tions for several minutes twice daily and afterward 
powdered with boric acid, with or without 1 or 2 per 
cent, salicylic acid. 

BURNS 

It is customary, following Hebra, to classify burns 
by three degrees. This classification is based on the 
extent of the pathology, varying from simple inflam- 
matory reactions of the skin to a primary necrosis. 
In a recent review of the management of burns Ravogli 
{Jour. A. M. A., July 24, 1915, p. 291) states that the 
best treatment is that which favors sloughing of the 
burned skin, maintains sterility of the resulting wound 
and promotes granulation and the forming of new 
epidermis. 

In burns of the first degree Ravogli believes that 
the application of a dry powder, such as talcum, bis- 
muth or burnt alum is the best treatment. Salves 
and baths are inadvisable because of the possibility of 
excoriation and maceration of the epidermis with sec- 
ondary infection. When there is severe pain a com- 
press moistened with a 2 to 5 per cent, solution of 
aluminum subacetate is applied to relieve the pain. 
As soon as the pain is relieved, the skin should be 
dried and a dry powder applied. 






TREATMENT OF BURNS . 493 

In second degree burns, as soon as the blisters are 
distended with serum they are evacuated, leaving the 
epidermis in place to protect the papillary layer. Com- 
presses of aluminum subacetate are advised here also. 
The application of compresses moistened with 1 per 
cent, picric acid solution have been advised, and also 
a solution of potassium permanganate of 1:3,000 or 
1 : 4,000. These solutions are difficult to handle and 
stain anything with which they come in contact. Over 
the compresses moist with aluminum subacetate a piece 
of oiled silk, cut to hold the dressing in place, is 
bound. This may be removed at intervals and the 
dressings again moistened. Such oily substances as 
carron oil, or oleum lini and aqua calcis may carry 
infection and should therefore be avoided. When the 
shreds of epidermis forming the blisters are easily 
detached they are removed with a forceps and scissors 
and the whole surface gradually cleared. The exposed 
surfaces may then be exposed to the air, for an hour 
at iirst, later for two or three hours. The surface is 
then covered with powder and sterile gauze. Little 
points which ooze and granulate are touched with 
3 per cent, silver nitrate solution and are covered with 
2 per cent, boric acid in petrolatum to prevent crust- 
ing. Under such treatment these burns heal in from 
ten days to two weeks. 

In burns of the third degree practically the same 
treatment is used. If pus forms compresses of 1 : 2,000 
mercuric chlorid solution are used until the lesion is 
clean and fever disappears. There is danger in too 
long continuing compresses of mercuric chlorid. After 
being exposed to the air for two or three hours when 
granulation has begun, Ravogli applies 2 per cent, 
borated petrolatum on English lint. When the granu- 
lations are pale and show a tendency to form pus, a 
mixture of castor oil and Peruvian balsam may be 
applied. If too long continued this dressing produces 
irritation. 

In burns of large areas of the surface of the body, 
other methods of treatment are often necessary. 

Kuss and others have advocated the covering of the 
burned area with a piece of caoutchouc paper in which 



494 . TREATMENT OF BURNS 

holes are cut. Through these the serum drains and the 
wound is moistened at intervals with salt solution. 

Parker (Jour. A. M. A., July 3, 1915, p. 16), after 
sloughing of the tissue has taken place, covers the 
wounds, or ulcers, especially in burns of the extremi- 
ties, with strips of adhesive plaster. 

After separation of the slough, ribbons of adhesive 
plaster from 1 to 1*4 inches wide and long enough to 
cover the area and lap over slightly are placed, leaving 
no granulations exposed. Its function is to keep in 
the serum and prevent cells dying from dryness. Over 
this are placed several layers of gauze to take up the 
secretion that works out between the strips at various 
places. 

The gauze is changed every day as it becomes soiled 
and every few days the adhesive plaster. This is 
done by cutting through it with a blunt scissors when 
it immediately falls away from the moist surface to 
which it does not become attached. Pus comes away 
with it The surface is sponged and a new dressing 
applied. Parker finds that burned areas so treated 
granulate smoothly, with little absorption of toxic 
products and but little pain to patients in changing 
dressings. Skin grafts placed under such dressings 
seem to grow as well or better than under gauze 
dressings. 

GENERAL TREATMENT 

As has been mentioned, over large, severely burned 
areas, Reverdin skin grafts may aid epidermization. 

An extensive burn practically always is accompanied 
by some systemic reaction. Patients may be stimulated 
with cafrein or strychnin, or morphin may be given 
to relieve the pain. 

Gastroduodenal ulceration, with nausea, vomiting, 
and acute nephritis are not wholly unusual sequellae. 
In such cases alkalinization of the patient, the use of 
Fisher's solution as mentioned under nephritis, and 
digitalis will aid in clearing up the condition. 

As the patient improves, a good diet, plenty of open 
air and the administration of iron aid in improving the 
general condition. 



DISEASES OF THE GENITO- 
URINARY TRACT 



ACUTE GONORRHEA 

While, theoretically, the most sensible treatment in 
this unfortunate common disease would be to place the 
patient in bed, on a milk diet combined with bland 
alkaline drinks and free catharsis, it is obviously 
impossible, in the majority of instances, to carry out 
such treatment. Consequently it should be aimed to 
get as near as possible to such general treatment. 

GENERAL TREATMENT 

Exercise. — The patient should be forbidden all vio- 
lent exercise. Running, swimming, dancing, gymnas- 
tics, and extreme exertion of any kind should be for- 
bidden. 

Suspensory. — Rest is obtained by the wearing of a 
suitable suspensory bandage. The organ should be 
straightened out and attached toward the abdomen. 
Ordinary suspensory bandages do not do this. The 
patient should be instructed to avoid sexual intercourse 
or various sexual excitants. 

Diet. — All substances which may bring on constipa- 
tion or excite the generative organs should be forbid- 
den. Alcohol, coffee, tea, highly spiced foods and con- 
diments, very acid or salty dishes, and various shell- 
fish should be forbidden. The use of tobacco in small 
amounts by those habituated to its use may be con- 
tinued, but excess is certainly contraindicated. 

Cleanliness. — The patient should be instructed to 
maintain scrupulous cleanliness. The organ should be 
covered with a clean dressing after each micturition. 
The patient should avoid frequent handling of the 
genitalia. After such handling the hands should be 
washed thoroughly, and the eyes should not be touched 
because of the danger of transferring organisms and 
bringing on a gonorrheal conjunctivitis. 



496 FLUIDS IN GONORRHEA 

Fluids. — The patient should drink freely of water. 
One of the best methods of diminishing pain during 
micturition is to increase largely the quantity of urine. 
It may be necessary to influence the reaction of urine, 
making it either alkaline or acid as conditions indicate. 

The best alkalmizers of the urine are the well-known 
potassium salts, the acetate, bicarbonate and citrate, 
and every physician has his favorite combination of 
these drugs. Any one of these salts is efficient if given 
in sufficient doses, though many physicians think a 
combination is better. The acetate is perhaps the most 
active alkali of the three, the bicarbonate the most 
disagreeable to take, and the citrate the pleasantest. 

The urine is more readily rendered alkaline by the 
administration of the alkali directly after a meal, at 
which time the urine is the nearest to neutral on 
account of the production of hydrochloric acid in the 
stomach. The amount of an alkali that should be 
administered cannot be determined except by examina- 
tion of the urine; in other words, if the object is to 
render the urine alkaline, enough should be given to 
cause that condition. Any of the following combina- 
tions are satisfactory : 

gm. or c.c. 

R Potassii citratis 501 or 3 ii 

Aquae 200| A3 viii 

M. Sig. : Two teaspoonfuls, in water, three times a day, 
after meals. 

[The water may be flavored with an aromatic, as pepper- 
mint, spearmint, wintergreen, or cinnamon, if desired.] 

It will often be necessary to administer the above 
dose more frequently than three times a day. Also, as 
an adjunct it is sometimes advisable to have the patient 
drink several glasses of artificial or natural vichy, or 
some other alkaline water, during the day. 

Or: 

gm. or c.c. 

ty Potassii acetatis 10 

Potassii bicarbonatis aa 10 

Potassii citratis 20 

Aquae cinnamomi 200 

M. Sig. : Two teaspoonfuls, in water, three times a day, 
after meals. 

Alkalies should not be pushed long if there is con- 
siderable mucus coming from the bladder, or if there 



3 iii 

3 vi 

flSviii 



URINARY ANTISEPTICS 497 

is bladder irritability, for it must be remembered that 
the bladder mucous membrane is accustomed to an acid 
secretion, and a continuous alkaline urine sooner or 
later causes irritability of the neck of the bladder, fre- 
quent micturition and even tenesmus. Also, if the 
urine becomes at all ammoniacal, the irritation of the 
bladder is made worse by alkalies, and the likelihood 
of deposits in the bladder is increased. 

URINARY ANTISEPTICS 

To render the urine antiseptic there are no better 
drugs than salol (phenylis salicylas) or hexamethylen- 
amin. 

As soon as the first acute symptoms are over, the 
alkali should be stopped, as it is not well for a healthy 
condition of the mucous membrane of the bladder to 
keep the urine alkaline for any considerable time. At 
this time it seems well to begin the administration of 
salol or hexamethylenamin, as thought best. If there 
is any irritation of the kidneys, salol, on account of 
one of its decomposition products being phenol, should 
not be used, phenol being irritant to the kidneys. If it 
is administered, it is well given as follows : 

gm. or c.c. 

I£ Phenylis salicylates 5| or 3 iss 

Fac capsulas siccas, 20. 

Sig. : A capsule every four hours. 

Hexamethylenamin, to be effective, must be given 
in acid medium, or no formaldehyd will be released, 
and its antiseptic action will be nullified. It may be 
given in a dosage of 5 grains three or four times a 
day in half a glass of water. 

COPAIBA AND SANTAL 

These drugs have long been used in gonorrhea for 
their action on the mucous membrane of the genital 
tract. They are indicated apparently for subacute and 
chronic gonorrhea rather than for the acute condition. 
As soon as posterior urethritis has developed, which 
occurs in the majority of cases of gonorrheal urethritis, 
one of the balsams is indicated, unless there is vesical 
irritation, as shown by great frequency of urination 



498 COPAIBA AND SANTAL 

with small amounts of urine passed. Santal oil seems 
to be one of the best preparations and may be admin- 
istered as follows : 

gm. or ex. 
fy Capsulas olei santali flexibiles. .aa Trt x 

No. 25. 
Sig. : A capsule three times a day, after meals. 

If there is no diminution in the amount of pus in 
the second glass of the two-glass test, and there are no 
symptoms of over-action of santal wood (viz., no pains 
referred to the ureters, or lumbar pains, and no special 
indigestion), two of these capsules three times a day 
may be taken. 

It should be emphasized that no patient with gonor- 
rhea can be well treated unless at each office visit he 
passes urine, that has been retained for at least three 
hours, into two glasses, he dividing the amount as 
nearly equally as his judgment permits. The washout 
from the urethra can thus be examined in the first 
glass, and the urine from the bladder and posterior 
urethra be examined in the second glass, and the con- 
clusions thus arrived at will many times decide the 
treatment that is needed. 

All balsam treatment may be stopped as soon as the 
posterior urethritis is cured. If, on the other hand, 
the posterior urethritis does not improve, the balsam 
may be increased in amount, or, if the posterior ure- 
thritis tends to become chronic, local posterior urethral 
treatment is indicated. It is also wise to demonstrate 
to the patient that, although the anterior urethral dis- 
charge may have ceased, he is not well until the pos- 
terior urethra is healed. 

New and Nonofficial Remedies contains the follow- 
ing preparations for this purpose : Arheol is an alcohol 
which is the chief constituent of sandalwood oil. It 
is claimed that because of its purity it does not occasion 
disturbance of the stomach or the kidney. It is put 
up in capsules of which 9 to 12 are taken daily. Car- 
bosant is the carbonic ester of santalol. It is put up in 
capsules containing 5 grs. each, of which two are 
given 3 times a day. Santyl is the salicylic acid 
ester of santalol, and thyresol is the methyl ether of 
santalol. These are but a few of the many prepara- 



LOCAL TREATMENT OF GONORRHEA 499 

tions of this class. Most of those not included in New 
and Nonofficial Remedies are marketed with extrava- 
gant claims, some with suggestive names and literature 
leading to self-medication by the patient. 

If it is preferred to use hexamethylenamin as a 
bladder and posterior urethra germicide treatment 
(and if the bladder becomes actually infected there 
probably is no better treatment), it may be given as 
follows : 

gm. or c.c. 

B Hexamethylenaminae 6\ or 3 iss 

Fac chartulas, 20. 

Sig. : A powder, in a glass of water, four times a day. 

LOCAL TREATMENT 

The local treatment of gonorrhea involves the ques- 
tion of irrigations or injections. Pedersen does not 
believe that irrigation is often indicated in anterior 
urethritis. He believes that there are only "two indi- 
cations that justify instrumentation of an acutely 
inflamed urethra, viz. : retention of urine not yielding 
to all the lesser means for its relief, and extremely 
severe posterior urethritis." It certainly appears not 
justifiable to give any great pressure to the delicate 
urethral membrane as occurs by any irrigation method. 
Such irrigations may not only force the gonococci into 
deeper tissues as well as into the posterior urethra 
and perhaps bladder, but may so injure the mucous 
membrane as to cause long protracted chronic inflam- 
mation and strictures. 

On the other hand, Luys believes that in the vast 
majority of cases injections are badly done and lead 
to complications, such as prostatitis, cystitis and vesicu- 
litis. To avoid these accidents the patient should not 
be given any syringe which holds more than 5 or 6 c.c. 
The patient should urinate before using the injection. 
The meatus and glands should be washed and the fluid 
injected first should be allowed to run out. The 
patient then reinjects, closes the meatus, holds the fluid 
five minutes and then allows it to run out. 

The number of substances used for such injections 
is legion ; chief, however, are silver nitrate and the 
organic silver preparations. Silver nitrate is used in 
a strength of 1 : 1,000. 



500 IRRIGATIONS IN GONORRHEA 

The silver compounds that may be used for this pur- 
pose are albargin, argentamin, argonin, argyrol, hego- 
non, novargon, protargol, sophol, cargentos, collargol 
and electrargol. All of these preparations are included 
in New and Nonofficial Remedies. The strength of 
the solution used varies with the preparation, argyrol 
from 5 to 20 per cent., protargyrol, 1 to 2 per cent., etc. 

The patient, as has been stated, should be carefully 
instructed first how to pass the urine and then how to 
use the syringe and how to retain the fluid. The 
length of time that he should retain it depends on the 
length of time that there is burning after the injec- 
tion has been evacuated. If the burning lasts a con- 
siderable time, the injection should be retained a 
shorter time. Unless there is a contraindication of 
much pain and burning, the retention of the silver 
solution for five minutes, and perhaps longer, is cer- 
tainly more likely to allow the germicide to penetrate 
more deeply. 

The injection may be used every three hours for the 
first twenty-four hours, and every four hours there- 
after. Every fourth day at least a smear of the dis- 
charge should be examined for the presence of gono- 
cocci. As they diminish in number the strength of the 
fluid is reduced and the frequency of its injection is 
diminished from four times daily to only twice daily. 

After the organisms have disappeared from the dis- 
charge for from three to seven days the injection is 
reduced to once a day, and from five to ten days later 
it is discontinued altogether. 

This frequent injection of the urethra would seem 
a little strenuous for the patient, and might need to be 
modified if it had caused much swelling and inflamma- 
tion. As mentioned under the section on physical 
therapy, hydrotherapy in the form of hot applications 
and hot sitz baths may give relief if much inflammation 
or irritation is present. 

IRRIGATIONS 

This method of treatment is more common on the 
continent than in this country. The number of drugs 
used for this purpose also embraces almost every drug 
of antiseptic nature in the pharmacopeia and elsewhere. 



ASTRIXGEXTS IN GONORRHEA 501 

According to Luys the chief and only contraindication 
is an acute local painful condition. Among the drugs 
used the principal ones are the silver salts, mercurial 
salts, potassium permanganate and bismuth salts. 
Very dilute solutions should be used to start. The 
water should be warm, distilled water. The technic of 
giving such irrigations is difficult, though simple, and 
should be thoroughly understood before it is attempted. 
The solution is placed in an irrigation douche-vessel 
which is fixed at a height of from three to five feet 
above the patient. The cannula is attached to a long 
tube leading from this vessel and there should be a 
stopcock to control the flow. The patient urinates, and 
lies prone. The genitalia are cleaned with an antisep- 
tic solution and a basin is placed to catch overflow. 
The glans is held with the left hand and the meatus 
held apart. The cannula is introduced. At first the 
anterior urethra is irrigated. The cannula being with- 
drawn and the fluid allowed to run out. The cannula 
is again introduced, the meatus closed against it and 
the patient instructed to bear down as though to uri- 
nate. The fluid then enters the bladder and posterior 
urethra. It is sometimes necessary to anesthetize the 
urethra by the injection of ten c.c. of a weak local 
anesthetic, such as 1 per cent, stovain. 

The irrigations should be employed at least once 
daily and should be continued as long as a discharge 
is present. This may be as much as two weeks ; they 
should then be gradually discontinued, giving irriga- 
tion every other day, twice weekly, and finally once 
each week. 

Potassium permanganate is used in strength of 
1:8,000. Albargin is used in strength of 1:1,000. 
Protargol is used in from 1 : 1,000 to 1 : 2,000 strength, 
and argyrol from 1 : 500 to 1 : 250. 

ASTRINGENTS 

As soon as the gonococci have disappeared and 
been absent for several days a continued catarrh of 
the anterior urethra is best treated by astringents, 
and there is probably none better than the generally 
used zinc sulphate. Pedersen uses this salt in solution 
up to 2 grains to the ounce (.4 per cent.), and advises 



502 ASTRINGENTS IN GONORRHEA 

injection twice daily, rarely three times daily, and then 
he gradually reduces the frequency. While zinc sul- 
phate is often combined with several other ingredients 
for injection, such as fluid hydrastis, boric acid, etc., it 
probably acts as well in simple solution, as follows : 

gm. or ex. 

fy Zinci sulphatis |50 or gr. viii 

Aquae 100| A3 iv 

M. Sig. : Use externally as directed. 

This subacute stage of gonorrhea should cease in 
about two weeks, and if it persists longer it seems 
probable that there is some complication of a previous 
inflammation or a localization that should be definitely 
treated. If at any time during this subacute stage the 
secretion shows gonococci, the silver albuminoid injec- 
tion may be used. During this stage the same restricted 
diet should be continued, but more exercise may be 
allowed. 

If posterior or anterior urethritis persists with gono- 
cocci absent after the period of subacute inflammation 
has passed, the use of silver nitrate solutions has been 
advised. The whole length of the anterior urethra 
may be treated through an endoscope by means of a 
cotton swab medicated with 0.5 or 1 per cent, nitrate 
of silver solution ; or there may be instilled by means 
of a deep urethral syringe a syringeful of a 1 : 5,000 
to 1 : 250 solution of nitrate of silver, or a few drops 
of a 0.25 to 0.5 per cent, solution. Such treatment 
should not be repeated oftener than once in five days. 
The passing of all instruments through the urethra, 
even in this late stage of gonorrhea, should be done 
with the greatest of care, and thin, bland oils are the 
best lubricants. 

If the morning drop persists follicular urethritis is 
probably present, irrigations are advisable, as if solu- 
tions pass from the anterior urethra back into the blad- 
der they cleanse the mouths of the follicles which are 
directed forward, and the retained secretions are thus 
removed. For this purpose a solution of 1 : 30,000 of 
bichlorid of mercury or a saturated solution of boric 
acid, or a 1 : 2,000 potassium permanganate solution 
may be used. The solution selected would be given by 
the ordinary irrigation apparatus, viz., a short glass 



VACCINES IN GONORRHEA 503 

urethral tube and the pressure necessary to cause the 
solutions to flow gently into the bladder. 

If there is great disturbance from the posterior 
urethritis, the patient should be put to bed. The 
anterior urethra may be washed with boric acid solu- 
tion and then the mucous membrane anesthetized with 
a 2 per cent, solution of eucain or 1 per cent, stovain, 
and a soft rubber catheter, 14 to 16 French, passed 
into the deep urethra. Then instill into the deep 
urethra 2 or 3 fluidrams (from 10 to IS c.c.) of a 
silver albuminoid solution, or a solution of nitrate of 
silver in strength of 1 : 5,000 to 1 : 1,000. Such instilla- 
tion may greatly relieve the patient of his distressing 
symptoms. This treatment may be repeated in a day 
or two, if it prove to be necessary. 

It should not be forgotten that these apparently 
severe symptoms of a posterior urethritis may really 
be a prostatitis, or even the beginning of a prostatic 
abscess. 

A posterior urethritis pure and simple in the acute 
stage of gonorrheal arthritis will rarely need irrigation 
treatment. As a general rule, it will be found that hot 
baths, absolute rest, a milk diet and the administration 
of alkalies will within twenty-four hours stop the 
intensity of the symptoms. 

VACCINE AND SERUM THERAPY 

Vaccines, serums, sensitized vaccines and autogen- 
ous serums have been used in gonorrhea and its com- 
plications with startling reports of success or of com- 
plete failure. These methods seem particularly adapted 
to the treatment of the complications. The time is not 
yet ripe to state what their actual value is. 

PROSTATITIS AND SEMINAL VESICULITIS 

The most frequent, and the only frequent cause of 
inflammation of the prostate and of the seminal vesi- 
cles is gonorrhea. Without regard to the importance 
of acute inflammation of these parts the chronic and 
persistent harboring of the gonococcus by these organs, 
making the carrier of these germs a menace to himself 
and others, makes the subject of vast importance. It 
is hardly necessary to state that most gynecologic 



504 PROSTATITIS 

inflammations are due to the gonococcus, and most 
frequently the infection is received innocently and is 
due to a latent gonorrhea, or a chronic prostatitis or 
vesiculitis due to an uncured gonorrhea in the male. 
Chronic gonorrheal infection of the prostate and semi- 
nal vesicles is of comparatively frequent occurrence. 
The symptomatic evidences may be slight. There 
often is an increased frequency of urination ; there 
may be a feeling of fullness or uncomfortableness in 
the perineal region ; there may be a slight sticky, or 
mucopurulent exudate and the urethral drop, and the 
urine may be cloudy. On the other hand, the urine is 
not always cloudy with this subacute or chronic pros- 
tatitis. * 

While it is probably rare to find gonococci in pros- 
tatic exudate a year after the original infection, it does 
occur, and before a year the gonococci may be fre- 
quently found when there are no apparent evidences 
of the previous gonorrheal infection. When from 
massage of the prostate and stripping of the seminal 
vesicles the examination of the slide from the drops 
of secretion exuded from the urethra show gonococci, 
of course the diagnosis is positive. If such an exam- 
ination shows no gonococci in a suspected individual, 
it has been suggested that from 1 to 2 c.c. (5 to 10 
minims) of a 1 per cent, solution of nitrate of silver 
be injected into the posterior urethra with the Ultzman 
syringe. The stimulation from this injection will 
cause, the next day, an increased discharge, which 
should cause gonococci to be found on microscopical 
examination, if they are still present. 

Besides the local symptoms above described of 
chronic prostatitis, patients who are suffering from 
this condition often have symptoms of neurasthenia 
and hypochondriasis. Men otherwise well, with no 
apparent cause for symptoms of nerve tire, should be 
carefully questioned as to previous gonorrheal infec- 
tion, and the prostate and any secretion that can be 
expressed from it should be carefully examined, even 
if the local symptoms are negative. 

Acute gonorrheal inflammation of the posterior 
urethra is, of course, readily diagnosed by the cloudi- 
ness of the urine. A later involvement of the pros- 



SUBACUTE PROSTATITIS 505 

tate or seminal vesicles is diagnosed by the finger 
passed well up the rectum and noting the enlargement 
and tenderness of the prostate, and, if the seminal vesi- 
cles are involved, by noting thier fulness and tender- 
ness. Normal seminal vesicles are hardly palpable. 

Acute inflammation of the prostate and vesicles 
should be treated with rest, a diet of milk and simple 
cereals, plenty of w r ater should be taken, and hot sitz 
baths once or twice a day. The urine should at first 
be rendered alkaline with potassium citrate during the 
acute irritation, and later hexamethylenamin or salol 
(phenyl salicylate) should be administered. There 
should generally be no urethral injections and no 
manipulation of the prostate, and certainly no passing 
of instruments into the urethra. If the prostatitis 
becomes localized and causes an abscess, of course 
the treatment is surgical interference. 

In subacute prostatitis the prostate should be gently 
massaged, and some of the exuded fluid which is 
received on a glass slide should be examined under the 
microscope for pus and gonococci. Generally, there 
will also be found living spermatozoa and often dead 
spermatozoa, with prostate epithelial cells, and perhaps 
crystals of spermin. The tenderness of the prostate 
determines the frequency and the amount of massage 
that it should receive ; perhaps every second day for a 
short time, and then twice a week. At each massage 
the seminal vesicles should be thoroughly stripped. 
During this subacute inflammation all violent exercise 
must be prohibited ; alcohol should certainly not be 
allowed, and the patient is usually better without 
tobacco than with it. Tea and coffee, if allowed at all, 
should be in small amount. Constipation should be 
guarded against, particularly in prostatitis. It is 
always best to wear a suspensory bandage during 
acute gonorrhea, and during acute and subacute inflam- 
mation of the prostate. 

The prognosis is good if the patient will give himself 
the proper rest in the acute condition, if he will take 
care of himself in the subacute condition, and will 
persist long enough in his treatment of the chronic 
condition. 



506 CHRONIC PROSTATITIS 

If gonococci are present in this secretion in subacute 
or chronic inflammation, vesical injections^ of weak 
silver solutions, such as from 1 : 500 to 1 : 1,000 of 
one of the albuminate silver preparations, should be 
given daily or every other day, and at least every other 
day or generally every day the prostate should be mas- 
saged while the solution is in the bladder. The patient 
then urinates and thus washes out the bladder. These 
bladder washings should soon be less frequently 
repeated, and as soon as the gonococci are found 
absent from the prostatic secretion, the bladder injec- 
tions are given only infrequently. A microscopic test 
should be made once a week for three or four times, 
and then again in a month. The gonococci remaining 
absent, the patient may be considered cured of the 
infection. The old assertion that when the gonococci 
had infected the prostate vesicles the patient could 
never be cured, but harbored them for the rest of his 
life, is probably not now true if the affected individual 
will allow himself to be properly treated before the 
germs have found a more permanent harbor deeper 
within the glandular tissue. 

In chronic prostatitis without gonococci, or after 
the gonococci have disappeared, besides massage of the 
prostate once or twice a week, local applications can 
be made by high injection of from 1 or 2 c.c. (5 or 
10 minims) of various silver solutions, the strength 
of which should vary from 1 to 3 per cent. Instilla- 
tions should not be used more frequently than once in 
five days. Ichthyol solutions have also been used for 
this purpose. The cold sound is occasionally of as 
much advantage in the posterior urethra as it is in 
gleety conditions of the anterior urethra. Not infre- 
quently the double closed catheter, which allows the 
circulation of cold water, is one of the best tonic treat- 
ments of the posterior urethra and prostate. Such 
treatment is indicated only in the chronic form of 
the inflammation when the prostate has not returned 
to its normal size, normal tone and normal feel. 

In chronic gonorrheal infections particularly the 
vaccine and serum preparations seem to offer most 
hope of success. They may certainly be given a trial. 



HYPERTROPHY OF THE PROSTATE 507 

Like any other inflammation that has become 
chronic, a patient who has become neurasthenic and 
mentally disturbed and perhaps below par physically, 
should receive tonic treatment and such a vacation as 
he may be able to take, and the local inflammation .will 
often rapidly improve when it has not improved under 
more active medication. It should be urged that after 
the gonococci have disappeared, too long use of instru- 
ments should be discouraged. 

CHRONIC HYPERTROPHY OF THE PROSTATE 

This condition should be distinguished from enlarge- 
ment of the prostate due to a subacute prostatitis, 
which is an inflammation that affects the ducts and is 
generally due to an infection that has come from the 
urethra. Although this enlargement of the prostate 
may persist for some time, proper local applications 
and massage will generally effect a complete cure. 

True chronic hypertrophy of the prostate develops 
insidiously and is of frequent occurrence as it is 
present, in various grades, in about 65 per cent, of all 
men after the age of 50. The treatment of this condi- 
tion is well discussed under three heads : prophylactic, 
palliative, and operative. 

PROPHYLAXIS 

As the etiology of chronic hypertrophy is not clearly 
understood, it is difficult to lay down a definite rule 
for prophylaxis. While it is probable that this is a 
normal accompaniment of old age, the reason that it 
occurs so frequently at an earlier age, from 50 to 60, 
may be because of excessive or abnormal sexual activ- 
ity. Investigations seem to show that benign hyper- 
trophy occurs very much more frequently in the mar- 
ried man than in the single man. 

There seems to be no question that frequent, and 
especially abnormal sexual excitement does congest the 
prostate, and repeated prostatic congestions lead to a 
slow hypertrophy. It is also probable that a bad heart 
which allows venous congestions, especially when the 
veins of the pelvis (and the hemorrhoidal veins espe- 
cially) are dilated, would become an impetus to passive 
congestion and later to hypertrophy of the prostate. 



508 HYPERTROPHY OF PROSTATE 

Persistent constipation would be another added cause 
of this passive congestion. Bladder- irritation and irri- 
tability, if frequently repeated and never completely 
cured, could be a cause; while varicocele could be 
another cause for prostatic congestion. In other 
w^ords, anything that tends to repeated pelvic acute 
congestion or chronic pelvic passive congestion may 
well be an exciting cause to the enlargement of the 
prostate, which organ is always apparently ready to 
enlarge after the age of 50. Consequently, any treat- 
ment that removes or prevents these congestions would 
be prophylactic treatment against hypertrophy of this 
gland. 

EARLY SYMPTOMS 

The early symptoms of an enlarging prostate are 
increasing frequency of urination, especially at night; 
slight delay in starting urination, especially early in the 
morning or when the bladder is full ; and a slight dimi- 
nution in the expulsive force of the stream. These 
symptoms have usually been present many weeks, and 
even months, before the physician is consulted. By 
this time the hypertrophy has advanced to a consid- 
erable degree, and enlargement of the prostate, as 
shown by examination, is generally positive. The 
question immediately arises as to whether palliative 
treatment should be advised or an immediate operation 
performed. 

Tt would seem unwise, even with the very low mor- 
tality when the operation is done at this period, from 
the fact that there is a mortality, to urge immediate 
operation. Neither the condition itself nor the opera- 
tion is really the cause of the mortality, but it is due to 
the concomitant or coincident insufficiency of the kid- 
neys, possibly to an arteriosclerosis. It should be 
remembered that when a man is suffering from chronic 
hypertrophy of the prostate he also has probably used 
his circulatory system to excess, the arterial tension 
is generally high, the heart may be in perfect condition 
but undoubtedly the left ventricle has become hyper- 
trophied to combat normally increased tension of 
the man's life and the increased tension of the arterial 
system due to advanced years. Also, although the 
urine apparently may be perfectly normal, the kidneys 



HYPERTROPHY OF PROSTATE 509 

are often imperfect at this age, as would be evidenced 
by repeated examinations of the twenty-four hours' 
urine on different diets and under different irritations 
or exertions. In other words, kidneys, that are perfect 
during the ordinary daily life, when the patient is sub- 
jected to an etherization or to the slight shock or dis- 
turbance of an operation, become insufficient, and ure- 
mic symptoms readily develop. Therefore, the treat- 
ment of the above condition should at first be palliative. 
The great source of danger is residual urine, i. e., 
the urine which remains in the bladder after the patient 
has urinated and which he cannot evacuate by volun- 
tary effort. That there is a residual urine can be deter- 
mined only by the passage of a catheter. A soft rub- 
ber catheter properly sterilized can generally be passed 
without difficulty, this after the patient has urinated, 
and after the parts are thoroughly cleansed and ren- 
dered aseptic. A study of the urine that the patient 
passed (and best a study of it in the two-glass test), 
and a study of the urine which may be drawn by cathe- 
terization, i. e., the residual urine, will not only deter- 
mine the character of the urine, but also the condition 
in the bladder. An acid urine, clear, without pus, 
without much mucus, without blood caused by the cath- 
eter rubbing over the prostatic urethra, shows that 
temporizing and palliative treatment should be the 
treatment elected. The evacuation of clear urine by 
the patient does not positively preclude the possibility 
of even a large amount of residual urine, as absolutely 
clear urine may be passed on repeated days and yet 
catheterization remove a large quantity of turbid 
residual urine. If there is no residual urine, good; 
sensible tonic treatment, a proper amount of rest, a 
properly regulated diet, good management of the bow- 
els, prevention. of chilling, and the happy medium of 
never attempting to hold the urine too long or on the 
other hand answering every frequent flitting desire to 
urinate, may hold the patient in the same condition for 
months or even years. It is undesirable to allow the 
patient to urinate too frequently, because it prevents 
the bladder from becoming normally distended, and 
the viscus becomes smaller and smaller until life 
becomes a misery. 



510 HYPERTROPHY OF PROSTATE 

If there is much mucus from the bladder, or if there 
is prostatic irritation sufficient to give local aching or a 
pain in the penis, the first treatment should be to draw 
the residual urine, then gently wash the bladder with 
a warm 2 or 3 per cent, boric acid solution. When 
the bladder washings are clean, the bladder should 
once more be filled with the warm solution and then 
the catheter removed and the patient allowed to pass 
the liquid. Care should be taken not to over-distend 
the bladder with these solutions. This washing may 
be done every day for a few times and then infre- 
quently, or absolutely stopped if the symptoms subside. 

If there is but little mucus in the urine, but vesical 
irritability, especially at the neck of the bladder or per- 
haps slight referred pain at the penis, the instillation 
into the bladder of 1 c.c. (15 minims) of a 1 per cent, 
solution of nitrate of silver, once in five days for a 
few times, or injection into the bladder of 60 c.c. 
(2 ounces) of a 1 : 5,000 solution of nitrate of silver 
and then withdrawing the catheter and allowing the 
patient to pass the solution, will frequently effect a 
temporary cure, and may give the patient relief for 
months. 

If pus is present in the urine and the condition is 
acute cystitis, the usual treatment of this condition 
must be given, viz., daily bladder washings with warm 
boric acid solution. If a chronic cystitis has already 
developed, the bladder-washing must be with some of 
the various silver soluttions, either an organic silver 
solution or a very weak nitrate of silver solution. The 
silver solution must not be used too frequently. One 
would hardly advise an operation during an acute 
cystitis, and would not urge it in chronic cystitis until 
the bladder was as surgically clean as possible ; in 
other words, prolonged, proper treatment, with the 
patient at rest. It is unnecessary to state that an opera- 
tion, when chronic cystitis is present, i. e., when an 
infection is present, is of much more serious prognosis. 
It is impossible to tell how much the ureters may have 
become infected or whether the kidneys have been 
injured from the infection in the bladder, to say noth- 
ing of their secretory ability. 



HYPERTROPHY OF PROSTATE 511 

Whenever there is cystic irritability or genito- 
urinary inflammation the diet should be just as care- 
fully regulated as is so well understood in specific 
urethritis, viz., in acute cystitis or in acute irritability 
of the bladder a milk and cereal diet should be given 
with rest and hot general baths. In chronic inflamma- 
tion of the bladder or of the prostatic region daily hot 
sitz baths are of great benefit, and the diet should be 
of simple, meats, ordinary vegetables, cereals, and 
fruit. Highly spiced foods should be forbidden, coffee 
and tea should be forbidden, and generally tobacco 
also, excessive use of alcohol should be interdicted, and 
no drugs should be given that could irritate the genito- 
urinary tract. As above urged, the bowels should be 
carefully regulated. Constipation does harm in all pel- 
vic inflammations. 

Acute irritability of the bladder may be partially 
relieved by the judicious use of drugs that render the 
urine alkaline, but when there is an enlarged prostate 
and any tendency whatever to residual urine, the urine 
should not be rendered long alkaline. The simplest 
prescription for this purpose is : 

gm. or c.c. 

ty Potassii citratis 501 or 3 ii 

Aquae gaultheriae 200| AS viii 

M. Sig. : Two teaspoonfuls, in water, three times a day, 
after meals. 

It is often inadvisable to have the patient drink a 
great deal of water as it will over-fill the blood-vessels 
(the age of the patient must not be forgotten), raise 
the arterial tension, increase the frequency of urina- 
tion, and may precipitate the occurrence of residual 
urine. 

If there is chronic cystitis, no drug is probably more 
valuable than hexamethylenamin, which may be given 
as follows : 

gm. or c.c. 

fy Hexamethylenaminae 10 1 or 3 iiss 

Fac chartulas, 20. 

Sig. : A powder in half a glass of water, three times a day, 
between meals. 



512 HYPERTROPHY OF PROSTATE 

CATHETERIZATION 

If there is residual urine and this (which may vary 
in amount from day to day) persists from day to day, 
it is only a question of time when the patient will have 
a sudden stoppage and be unable to empty the bladder 
and must send for a surgeon for immediate catheteri- 
zation on account of distention of the bladder with 
resulting paralysis. This having once occurred, some 
surgeons advise the use of a catheter continuously. It 
is possible in such an instance that if a proper attendant 
with the most careful cleanliness uses the catheter at 
least three times in twenty-four hours, and perhaps 
better four times, in a few days the bladder may return 
to its proper tone and may be as good or better than 
it has been before for a number of months, i. e., may 
not contain so much residual urine. This should be 
tried. If, on the other hand, the bladder does retain 
residual urine, and the urine tends to be alkaline and 
turbid, the man must be given a catheter to use him- 
self, either once in twenty-four hours to remove all 
residual urine, or three times in twenty-four hours if 
he cannot at any time well evacuate his bladder. This 
kind of treatment is sometimes necessary on account 
of the inadvisability of operating, but is generally inex- 
cusable, as it is only a question of time when such a 
bladder will become seriously infected and chronic 
cystitis, incurable, will be the result, and cause the 
death of the patient. Therefore, unless there is some 
positive reason why a man can not be operated on, 
operation should be advised, and advised before infec- 
tion has occurred. 

Some patients develop a chill after the passage of 
even a soft rubber catheter, or even have w T hat has been 
called the urethral fever, with considerable rise of 
temperature for some hours. This is not of frequent 
occurrence, and may never be seen by an individual 
practitioner. Other surgeons have seen it so frequently 
that they recommend the administration of some 
drug to prevent this hyperirritability of the urethra, 
such as bromids, and even quinin has been recom- 
mended. If such a reaction occurs, the patient should 
be kept in bed for twenty-four or thirty-six hours and 



HYPERTROPHY OF PROSTATE 513 

treated symptomatically. No harm seems to come 
from the disturbance. 

Simple palliative treatment of the condition being 
unsatisfactory, reflex pain in the penis or irritability 
of the bladder, persisting, cystoscopy should be care- 
fully done, and the possibility of a stone in the bladder 
should be considered. It must, however, be urged that 
a mild subacute condition is often precipitated into an 
acute one by such instrumentation. However, it is a 
means to an end, L e. } positive diagnosis of the condi- 
tion, and must often be done, but not done without 
due and careful consideration. To save repeated 
instrumentation, at the same time the bladder is cysto- 
scoped, it is well to pass a catheter into each ureter to 
examine the urine from each kidney separately. The 
results of this examination will aid in the decision as 
to whether or not an operation should be performed. 

OPERATION 

It is the object of the careful physician and- surgeon 
to aim to determine, when palliative treatment is use- 
less or in any given patient is becoming useless, to 
advise operation if the kidneys and circulation are in 
good condition before the patient becomes miserable, 
before the bladder has become infected, before the 
bladder has become seriously thickened, and before it 
has become paralyzed from over-distention or has 
become badly contracted from protracted and frequent 
efforts to expel urine over the obstacle of the enlarged 
prostate. As above stated, infection of the bladder may 
creep up toward the kidneys, and with infection of 
the bladder, and even without it, continued pain and 
irritation in this region may cause a general debility, 
loss of appetite, emaciation and feebleness. Of course, 
any of these conditions being present when the patient 
first comes to the physician would demand, first, rest, 
careful preparation of the bladder and the pushing of 
nutrition, and second, operation ; but the patient having 
been under a physician's care the operation should be 
advised and done before he reaches this sad condition. 

Which particular operation is best for a given indi- 
vidual, or the technic of the operation are questions of 
surgery ; it is enough for the physician to decide that 



514 HYPERTROPHY OF PROSTATE 

an operation is necessary. The results of perineal 
prostatectomy are surprisingly good when one takes 
into account the advanced age of many who submit to 
the operation, the frequent coincident cystitis, the his- 
tory of prolonged pain and often debility of the 
patients, and the impairment of circulatory and excre- 
tory organs concomitant to their age. Many patients 
over 80 years of age are operated on with good results 
and their lives greatly prolonged by the operation, and 
the mortality has been placed even below 4 per cent. 
The differential diagnosis between tumors of the 
prostate and simple hypertrophy of the prostate can not 
well be described. The greater amount of pain in most 
tumors of this age (the most frequent being cancer), 
with the greater rapidity of growth, with the nodular 
feel and enlargement in all directions as well as into 
the bladder, generally quickly shows that the enlarge- 
ment is malignant and not benign. 



OBSTETRICS AND GYNECOLOGY 



TOXEMIAS OF PREGNANCY 

The disturbances which occur during pregnancy and 
some of the severe conditions at parturition are due to 
varying causes, and the treatment that is efficient and 
satisfactory in one instance may not be efficient in 
another. 

Various causes have been associated with uncontrol- 
lable vomiting and toxemia of pregnancy. The view 
has been advanced that the condition is essentially 
anaphylactic in character. Further, intestinal indi- 
gestion, disturbances of the parathyroids and thyroid; 
disturbances in the fetal organism, in the placenta, in 
the kidneys and in the liver have been incriminated. 

When instances occur which are positively demon- 
strable of serious toxemias being caused by prolonged 
constipation, it is certainly logical to presume that con- 
stipation even in a mild form is provocative of the 
absorption of toxins that should have been eliminated 
by the intestines. These toxins seriously impair the 
perfect activity of the liver, to which they first go 
through the portal circulation. If the liver is so con- 
tinuously irritated it can not well do its normal work, 
and more or less toxins or irritants to metabolism soon 
get through this filter into the systemic blood and cause 
nervous, circulatory and kidney irritations. Such irri- 
tations at first, and perhaps continuously, may be incon- 
sequential, but they may be the forerunners or the 
instigators of serious conditions in the latter part of 
the pregnancy. A primary axiom in pregnancy, then, 
should be that constipation must not be allowed, and 
such means must be inaugurated and persisted in as 
will prevent constipation, intestinal stasis, intestinal 
fermentation, putrefaction and the absorption of tox- 
ins If any one of the digestive organs is not prop- 
erly functioning it should be assisted, if possible, and 
the diet so arranged as not to aggravate this disabled 
organ, and to relieve it of as much work as possible. 



516 TOXEMIA OF PREGNANCY 

HYPOTHYROIDISM 

It has been demonstrated, apparently, both physio- 
logically and clinically, that the thyroid gland normally 
hypersecretes during pregnancy. If the thyroid does 
not secrete properly, various toxemias occur. A mal- 
secreting thyroid may be related to pernicious vomit- 
ing during pregnancy, can certainly interfere with the 
nutrition of the fetus, and can interfere with the 
health of the mother. 

If by a careful study of the pregnant patient it is 
decided that the thyroid gland is not properly secret- 
ing, thyroid substance should be administered. The 
dose during pregnancy should be small. Just preced- 
ing parturition, it is feared that eclampsia may occur, 
and especially if the kidneys are insufficient, thyroid 
may be given in larger doses. If a patient gives birth 
to a child showing imperfect development or symptoms 
of under-thyroid secretion, although it might not be 
a cretin, thyroid may be administered to the mother 
throughout her subsequent pregnancies, unless symp- 
toms forbid its use. A daily dose for a pregnant 
patient, short on thyroid secretion, should not be more 
than 0.20 gm. (3 grains) once a day, while a patient 
who shows serious toxemia or critical symptoms of 
metabolic poisoning should receive 0.30 gm. (5 
grains) three or four times a day for a short period. 
A patient needing thyroid just before or during par- 
turition may be given 0.60 gm. (10 grains) once or 
twice, while a patient with eclampsia may be given 
1.30 gm. (20 grains) at one dose. Other preparations 
of thyroidin or Kendall's prepartions may also be used. 

OTHER CAUSES OF TOXEMIA 

Malnutritions of the fetus and degenerations of the 
placenta may cause the formation and absorption of 
toxins that will poison the mother. Such toxemias 
partake of the nature of blood poisoning. The cause 
being discovered and improvement not soon taking 
place would seem to call for cleaning out the uterus — 
this, of course, after a consultation. 

An uncomplicated true nephritic toxemia should 
certainly be discovered. A uremic condition from 
nephritis of pregnancy must almost always be a pro- 



VOMITING OF PREGNANCY 517 

gressive condition. Consequently a progressive chronic 
nephritis can only be overlooked by utterly neglecting 
to make proper examination of the urine. If a chronic 
nephritis, by evidences in the urine, shows a pro- 
gressive inflammation, a final toxemia, due to allow- 
ing a pregnancy to continue too long before interfer- 
ence, should be prevented. Consequently the most 
serious toxemias and eclampsias are those that do not 
present kidney symptoms or signs until the last moment, 
and these toxemias are due primarily to disturbances 
of other organs than the kidneys. 

If the kidneys were previously healthy, i. e., if an 
insidious chronic interstitial nephritis were not pres- 
ent, a nephritis due to pregnancy should be quickly 
recognized by the albumin in the urine. Therefore, an 
examination for albumin and casts is usually sufficient 
to show whether the kidneys are in primary trouble 
or not. 

TREATMENT 

Byers (Brit. Med. Jour., May 22, 1915, p. 2838) 
believes that every effort should be made to relieve the 
kidneys by getting the skin and bowels to act and by 
the administration of a simple non-nitrogenous diet. 
If there be headache or edema the patient, in addition, 
should be kept in bed and should have hot baths, 
free purgation and a milk diet ; and if the state of 
affairs becomes more severe, warm saline lavage of 
the stomach and intestines is useful. In the nephritic 
cases, if in spite of this method of management the 
patients get worse, labor should be induced. One of 
the most important points emphasized is that a preg- 
nant woman's urine must be analyzed once a month 
during the first six months of gestation, and at least 
once a fortnight after that period. 

VOMITING OF PREGNANCY 

The cause of severe vomiting of pregnancy has not 
been determined. The condition most frequently 
appears between the third and fifth week of preg- 
nancy. Among many causes which have been sug- 
gested are reflex influences such as pressure on nerves 
connected with the uterus, stomach and other abdom- 
inal viscera (and of these the most important are those 



518 UTERINE DISPLACEMENT 

due to displacement of the uterus and its adnexa) 
neurotic or hysterical, and toxemic. The latter natu- 
rally gives the most trouble because, primarily an auto- 
intoxication, it is almost invariably a combination of 
several evils. 

First, then, a complete history of the patient should 
be taken, an opinion formed as to her normal mental 
or nervous temperament, and a thorough and complete 
physical examination made. If the condition is due to 
hysteria, the patient should generally be isolated and 
moved if possible to a situation where she will have 
an entire change of surroundings and attendants ; the 
treatment then becomes mostly hygienic and sugges- 
tive. 

UTERINE DISPLACEMENT 

If examination reveals a misplaced uterus (and 
probably a retroversion is that most frequently found), 
replacement should be made immediately and a prop- 
erly adjusted pessary placed to maintain the correction 
until such time as the enlarging uterus will retain its 
proper position unaided. Occasionally adhesions may 
be found which prevent the manual correction of the 
fault. The condition then becomes more formidable, 
and recourse must be had to surgery. The same 
holds good in incarceration, and in this condition not 
infrequently corrective measures result in abortion. 
Erosions of the cervix, cicatrices, and polypi may be 
causes of the nausea and vomiting, and these if found 
should receive proper attention. However, surgical 
procedures, unless of a most trivial nature, should be 
reserved as a last measure, since they are liable to 
induce abortion, as are also such procedures as may 
require either a tampon of any considerable size, or 
packing of the vagina. 

If the vomiting still persists after all corrective 
measures possible have been made, there remain two 
conclusions : the vomiting is either idiopathic, or due 
to intoxication. The former term, of course, dodges 
the issue, but nevertheless brings the treatment under 
two headings, and the conclusion to be drawn from the 
mass of statistics seems to confirm unquestionably the 
comparative uselessness of drugs to meet either condi- 



NUTRITION IN TOXEMIC VOMITING 519 

tion. Almost everything has been used, and with no 
further benefit generally than a temporary mitigation 
of the symptoms. 

SUPPORTING NUTRITION 

The two great difficulties are the maintenance of 
the patient's nutrition and the combating of the pros- 
tration caused by the vomiting. Under whichever 
heading we choose to meet the case, hygienic mea- 
sures stand first and nothing should be omitted which 
tends to their furtherance. The diet should be of the 
simplest, and milk should form its bulk. One after 
another of its simple dishes must be tried, to be dis- 
carded if they are not retained. When the patient is 
first seen, if the stomach is washed out and nothing 
allowed but water for twenty-four hours, the bowels 
being thoroughly cleaned out meanwhile, milk will 
generally be retained. Just before giving the milk a 
small dose of cocain, 0.01 gm. (1/6 grain) may cause 
it to be retained. If it is retained, the drug may be 
given previous to further administration of food, les- 
sening the dose each time, and, not infrequently, when 
a placebo is ultimately substituted for them, the food 
will be retained as well. Sooner or later, unless con- 
quered, even these so-called idiopathic cases are found 
to have their etiology in intoxication and elimination 
becomes the main point of all treatment. 

The urine of course should be examined with great 
frequency and close watch should be kept on the 
elimination of solids, but an undue anxiety because 
of their diminution should not be felt when the intake 
of food or the food retained is small. A due regard 
to this should be kept in mind. 

The bowels should be moved freely once a day. A 
single dose, 0.25 gm. (4 grains) of calomel with a little 
bicarbonate of soda, 0.25 gm. (4 grains) is preferable 
if it can be retained ; if not, a daily enema must be 
given. If there appears to be any sluggishness on the 
part of the small intestines, 0.001 gm. (1/60) grain) of 
physostigmin salicylate should be given hypodermati- 
cally once or twice a day, as may be sufficient. 

Daily warm baths, with massage, plenty of fresh air, 
the patient kept in bed, the avoidance of the odor of 



520 NUTRITION IN TOXEMIC VOMITING 

cooking food, and the avoidance of all measures that 
tend toward excitement are of advantage. Counter 
irritation by mustard plaster or turpentine stupes 
placed over the stomach is generally a help and some- 
times efficient. Also carbonated or effervescing drinks 
will often be retained when "still" liquids are vomited. 

Sodium (or potassium) bromid is often of service in 
these cases. It is best given in one gram (15 grains) 
doses, well diluted, by mouth, if possible ; if not, by 
rectum and repeated every two or three hours until 
the vomiting is conquered or the treatment proves 
useless. 

Although bromids appear to be efficient, thyroid is 
not infrequently of use. It should be tried in small 
doses, say 0.20 gm. (3 grains ), and if retained, perhaps 
larger doses, up to 0.50 gm. (7y 2 grains) every four 
hours for a sufficient number of times to prove or dis- 
prove its efficiency. 

Zuloaga {Arch. Mens. d'Obstet. et de Gynec, 1914, 
iii, p. 433) has called attention to the relation of 
adrenal insufficiency to such toxic vomiting. In several 
severe cases in which the adrenals were found to be 
lacking in function he gave 10 drops of epinephrin 
every eight hours. All symptoms subsided and the 
pulse and blood pressure returned to normal. The 
epinephrin was suspended after a month and the women 
began to vomit anew, so that the epinephrin was 
resumed and 5 drops given every twelve hours until 
delivery. During the latter months he alternated two 
weeks of the epinephrin with two weeks of calcium 
glycerophosphate. 

The food, as above stated, should be liquid, and pref- 
erably milk, while buttermilk (cold), koumiss, and egg 
albumin lemonade are useful. Generally small quan- 
tities only should be given, and at frequent intervals. 
When the liquid food becomes well tolerated, semisolid 
food and the simpler dishes, one after another, may be 
tried. 

When all measures have failed to control the vomit- 
ing and before the patient has actaually reached a dan- 
gerous condition of prostration, consultation should 
be had and measures should be taken to empty the 



ECLAMPSIA 521 

uterus. Naturally, of course, one waits as long as pos- 
sible before doing this, and not infrequently waits too 
long ; hence this caution. 

ECLAMPSIA 

There is probably no condition that the medical man 
has to cope with that makes, from prodrome to seque- 
lae, such demands on his capabilities, his judgment, and 
his tact as does the symptom complex of this toxemia, 
for intoxication it is, poorly though we may understand 
it and little as we know of its etiology. Having its 
cause in some disturbance of the chemistry of either 
internal secretion or metabolic function, or. both, its 
treatment must necessarily be elimination until an 
increased knowledge of the condition permits it to 
be corrective. 

When it is possible to take the patient to a hospital, 
this should be done at once, for a case of eclampsia can 
at any moment present conditions which even the 
resources of a hospital, with its trained attendants, find 
difficulty in meeting, and these conditions can change 
with a rapidity wdiich none but institutional resources 
may attempt to meet. Whatever difference of opinion 
there may be concerning other features of this condi- 
tion, there can be no question that more cases are saved 
under institutional treatment than under any other, and 
only by reason of their increased facilities. If it be 
impossible to take the patient to an institution, and 
home treatment becomes a necessity, then the first thing 
to do is to prevent self injury to the patient by instruct- 
ing some one present how to hold a towel, cork, or a 
rubber eraser between her teeth, and to keep her on 
the bed. 

EXAMINATION 

Next, a thorough examination should be made, and if 
there are convulsions present or the examination starts 
one, a sufficient amount of chloroform may be given 
to allow the examination to be completed, and that 
thoroughly, for it is more important to know the exact 
condition present than to start any treatment with an 
incomplete knowledge of the case. 

The examination having been completed, if delivery 
is indicated the cervix can usually be completely dilated 



522 TREATMENT OF ECLAMPSIA 

under chloroform without instrumentation (i. e. y with 
the hand), forceps applied, and delivery completed. 
The placenta should generally then be removed, not 
waiting the usual twenty minutes, and the method of 
Crede is preferable. 

Generally there is a tendency to profuse hemorrhage, 
and the placenta having been removed, the uterus 
should be thoroughly irrigated with hot physiologic 
saline solution and it and the vagina packed with sterile 
gauze. However, the packing being in readiness, it is 
good judgment to wait a few moments before using 
it to see if the hot irrigating solution provokes sufficient 
contraction to stop the bleeding, for if it does, there is 
avoided the presence of an unnecessary foreign body 
in the uterus. 

Laceration, if present, should generally be repaired 
at once, always if it has caused hemorrhage. If not, 
the patient's condition may occasionally make the post 
ponement of the repair advisable. 

If indications for immediate delivery are not found, 
i. e., if the cervix is not much shortened or not much 
softened, the os undilated, and few or no uterine con- 
tractions (and this last is the most important deter- 
mining factor, since uterine contractions appear to 
excite the eclamptic convulsions) eliminative treat- 
ment should be started. If there is stertorous breath- 
ing, with small pupils, and slow, full, high tension 
pulse, and if the patient be more or less comatose, 
"bleeding" is indicated, and from 150 to 250 c.c. of 
blood should be removed, but whether or not this 
should be replaced with physiologic saline solution only 
the condition of the patient at the time can determine, 
certainly not if there is any edema. If it seems desir- 
able, the quantity of saline introduced should not be 
less than three or four times that of the blood with- 
drawn. Next flush out the colon with saline solution 
and allow 1,000 c.c. or more to remain for absorption, 
provided of course that there is no edema, and par- 
ticularly should the lungs be carefully examined with 
this in mind. Next, wash out the stomach if possible, 
and if done at all do it thoroughly, leaving in it 0.40 
gm. (6 grains) of calomel, with a little sodium bicar- 
bonate. Then apply the hot pack, and when perspira- 



STIMULATION IN ECLAMPSIA 523 

tion ceases, usually in about half an hour, dry the 
patient's skin thoroughly and keep her between 
blankets. The hot pack may be repeated in two or 
three hours, if necessary, and if there is vomiting the 
stomach may again be washed out, leaving in it another 
dose of thyroid, and a smaller dose of calomel should 
there be reason to believe that the first dose was 
vomited. In short, this eliminative treatment must be 
kept up until the uterus can be emptied. If it seems 
inadvisable to w r ash out the stomach calomel may be 
given by mouth in the dose above referred to. 

STIMULATION 

Bladder distention is common and must be borne in 
mind, catheterization frequently being necessary every 
six or eight hours for several days after delivery. 

Should stimulation be necessary, epinephrin hypo- 
dermatically, with or without physiologic saline solu- 
tion, may be used to advantage. Strychnin is gener- 
ally advised, but its use in conditions of cerebral 
excitation seems inadvisable. Certainly not more than 
one dose should be given and that not over 1/30 of 
a grain. If further stimulation appears to be needed, 
another drug should be substituted for it — either 
caffein hypodermatically, or as black coffee by the 
mouth, and this may be followed, if another change 
seems advisable, by the hypodermatic use of camphor 
in olive oil (1 c.c. of the saturated solution), and this 
may be continued at half-hour intervals. 

After delivery, if a sedative is needed, there is none 
better than a combination of sodium bromid, 2 gms. 
(30 grains), and chloral hydrate, 0.50 gm. (7]/ 2 
grains), well diluted and given by rectum. This may 
be repeated in an hour if necessary, but a single dose 
is generally sufficient. Morphin, too, is frequently 
advised and given, but in such a condition as this it 
would seem contraindicated in practically every 
instance. There is no pain to combat, and usually the 
patient will sleep from mere exhaustion if her "ner- 
vousness" is controlled. 

The quantity of morphin required to control this ner- 
vousness will of necessity be altogether more than nec- 
essary to meet every other condition, while on the 



524 PUERPERAL INFECTION 

other hand, if her condition is approximating coma, 
morphin becomes about as dangerous a drug as could 
be given her. 

When delivery is completed the danger is by no 
means over, and a careful watch of the patient is nec- 
essary, for it must be remembered that the sequelae 
of this condition are numerous and a patient can not 
be called out of danger until at least ten or twelve 
days have passed, and prognosis at any time before this 
is little more than a guess. 

Should the child survive, it is in all probability also 
toxic. It should be given water freely, and also, per- 
haps, colon irrigation once or twice daily. Prognosis 
as to its survival should be absolutely declined. 

PUERPERAL INFECTION 

Though septic infection after parturition occurs 
much less often than even a few years ago, it is still 
sufficiently frequent to necessitate resort to every pos- 
sible method of prevention and to the thorough con- 
sideration of effective but non-meddlesome treatment. 

This infection occurs most frequently in one of two 
general forms. One is a typical blood-poisoning or 
sapremia, which is caused by the absorption of toxins 
or decomposition of products of substances that are 
undergoing putrefactive or other chemical changes in 
the genital tract. Of course the most frequent sub- 
stances causing such poisoning are retained fragments 
of the placenta or membranes, or, if there is any 
obstruction to the exit of the normal lochia, there may 
be absorption from this. Such poisoning may be 
termed an auto-intoxication or autotoxemia. This 
poisoning may cause more or less rise of temperature, 
but it may not be high, and although an increased 
temperature in the first few days after parturition may 
be due to a bowel infection, to the absorption of bowel 
toxins, to some disturbance of the mammary glands, 
to some bladder or kidney disturbance or, of course, 
to some acute infection to which the patient may have 
been exposed, still, generally, the cause of such fever 
will be found to be in the genito-urinary tract. Slight 
injuries of the uterus, vagina or perineum during par- 
turition may allow absorption of and poisoning by dis- 
charges that would otherwise be innocuous. 



PUERPERAL INFECTION 525 

The other more serious cause of puerperal infection 
or puerperal fever is the absorption and circulation of 
pathogenic bacteria. Of these may be mentioned some 
varieties of streptococcus, pneumococcus, staphylococ- 
cus, gonococcus, and perhaps not infrequently the colon 
bacillus. Localized infections and more or less general 
disturbance from the last three of these pathogenic 
germs may not be serious infections as far as the imme- 
diate consequences are concerned and perhaps could 
hardly be called septic fever. Infections, however, from 
some form of streptococcus and occasionally from the 
pneumococcus are always serious ; the patient is septic 
and is suffering from dangerous septicemia. A puer- 
peral streptococcic infection quite commonly, though 
not always, will show a bacteriemia and may have as 
a complication endocarditis, even the malignant type, 
with perhaps associated local lesions such as pneu- 
monias, pleurisy and kidney infection, a pyelitis or a 
localized septic process in the kidney substance. Such 
a general infection is usually associated with more or 
less pelvic inflammation and pelvic tenderness, but is 
commonly without any pelvic abscess or purulent dis- 
charge. 

It can easily be understood how a slight injury or 
even a denuded surface of mucous membrane in the 
genital tract, consequent on parturition, with its sur- 
rounding vascular supply normally increased and 
lymphatic supply perhaps increased owing to the needs 
of the previous pregnancy, gives such a dangerous pos- 
sibility and almost a probability of the absorption of 
poisons and germs. A certain amount of abnormal 
absorption generally occurs, but is combatted by the 
normal woman. Such small absorptions are probably 
the cause of the frequent slight rises of temperature 
which last for a few hours or a day and then disappear, 
representing the normal neutralization of such toxins or 
the normal rendering inert of such germs. In other 
words, the resistance of the patient has proved entirely 
sufficient to combat the infection. 

If we accept the wound or abrasion theory of most 
puerperal infections the poison is really external to the 
body and is absorbed, unless there is some previously 
localized infection, such as that from a gonococcus. 



526 PUERPERAL INFECTION 

Consequently, the prevention of infection before, dur- 
. ing and subsequent to parturition, proper cleanliness 
and care of the patient without meddlesome and 
obstructive treatment or methods of treatment, and 
without removing Nature's own protective secretions, 
are the objects at which to aim. 

PREVENTION OF INFECTION 

Most of the preventive measures are too well under- 
stood to require more than enumeration. The selection 
and preparation of the room, the prepartion of the 
patient and of himself are well understood duties of the 
attending physician. The nurse also well understands 
the preparation of herself. A few details, however, 
should be emphasized. The nose of the patient should 
be gently sprayed and cleansed with an alkaline or mild 
antiseptic solution. The mouth and throat should be 
washed with some mild antiseptic mouth-wash, and the 
teeth thoroughly cleansed. The nurse should not give 
the patient a vaginal douche unless ordered to do so by 
the physician. The nurse should be free from any 
purulent discharge, especially from the nose, throat or 
even ears. She cannot be too careful in observing the 
greatest possible cleanliness in the care of the vulva and 
the vaginal discharges, with the use of such antiseptic 
solutions and gauze as the physician directs. If the 
patient must be catheterized, too great care cannot be 
taken to prevent infection of the bladder. 

Although a physician may take every means possible 
for personal disinfection and wear a sterilized gown 
and rubber gloves, it seems, except in isolated 
instances, unjustifiable for him to accept a case of 
obstetrics while he is in attendance in a case in which 
there is contagion, or immediately subsequent to hand- 
ling such a case, whether it be scarlet fever, erysipe- 
las, measles or diphtheria. After having cared for a 
patient with puerperal fever, he should not accept 
another case of obstetrics for some time and he should 
not attend a case of obstetrics while he is caring for 
any septic patient. 

The patient ordinarily should not be given a vaginal 
douche just before parturition. Very frequently one 
vaginal examination by the physician, to determine 



PUERPERAL INFECTION 527 

the exact position of the child and the condition of the 
os uteri, is all that is needed. This examination should 
be made after sterilization of the hands and with the 
use of rubber gloves. When there is any delay in a 
normal labor, any apparent malposition, or other com- 
plicating disturbance, several vaginal examinations 
must be made. Of course in all operative interference 
manipulations are more or less necessary, and although 
the instruments may have been properly sterilized, 
injuries to the parts are very likely to occur and the 
danger of future infection is much greater. 

If there is any purulent catarrh of the vagina, espe- 
cially if gonorrhea is present, cleansing and perhaps 
mildly antiseptic douches should generally be used. 
On the other hand, with a normal vagina it seems 
unwise to remove the secretions which facilitate the 
expulsion of the child and at the same time protect the 
mucous membrane. 

There is a difference of opinion as to the proper 
management when portions of membrane or of the 
placenta are found by examination of the expelled 
after-birth to have been retained. Some obstetricians 
would leave these retained substances to be loosened 
and expelled by natural processes, when ordinary gen- 
tle manipulation of the uterus does not expel them. 
Others believe that the sterilized, rubber-gloved hand 
should gently clean the vagina, and, if necessary, the 
uterus. The removal of retained portions of the pla- 
centa may prevent unpleasant and even dangerous 
hemorrhage. 

The routine administration of fluidextract of ergot 
three or four times daily for several days after par- 
turition in 1 c.c. (15 minim) doses, is believed by some 
modern obstetricians to aid and hasten involution of 
the uterus. If for any reason ergot is not tolerated or 
is inadvisable, quinin in 0.2 gm. (3 grain) doses twice 
a day may be of benefit in furthering this object. The 
use of pituitary extracts is now a recognized clinical 
procedure in such cases, but they should be given with 
caution as to dosage. 

TREATMENT OF PUERPERAL INFECTION 

If some form of puerperal infection has occurred, of 
course the first decision is as to whether or not it is 



528 PUERPERAL INFECTION 

local or general. In a local or pelvic disturbance with 
more or less rise of temperature but without any symp- 
toms of general infection, the treatment should be con- 
servative and more or less symptomatic. The bowels 
should be carefully attended to, the diet should be sim- 
ple but sufficient, large amounts of water should be 
drunk to dilute all the secretions, and Fowler's position 
should be used more or less continuously to encourage 
drainage. Again, vaginal douches generally should not 
be given. 

It has been shown that the action of yeast increases 
leukocytosis and more or less inhibits intestinal intoxi- 
cation; therefore its administration is good treatment 
in most infections and is very valuable in pelvic infec- 
tions. From one-sixth to one-fourth of an ordinary 
compressed yeast-cake, dissolved in a glass of water, 
should be given three times a day, unless it causes too 
much looseness of the bowels. Vaginal douches of 
yeast solutions have been used and are said to be of 
value. 

Of course the vaginal discharge, or, better, the 
uterine secretion directly obtained, should be studied 
bacteriologically to decide, if possible, what infection 
is present. According to Watkins (Am. Jour. Obstet. 
and Dis. Women and Child., 1913 Sept., abstr. Jour. 
A. M. A,, 1913, lxi, p. 1485), the bacteriologic exam- 
ination of vaginal and uterine secretions is of relatively 
small value, as the results are often uncertain and 
misleading. Blood-cultures are the only means at pres- 
ent of accurate diagnosis of the variety of infection. 
The result of this examination may suggest the use of 
an antiserum or a vaccine, if either be deemed advis- 
able. The blood should also be examined for patho- 
genic bacteria. 

If a parturient patient has a sudden chill more or 
less severe, with a rapid rise of temperature which 
persists in some degree and is not intermittent, and a 
rapid pulse, puerperal infection has probably devel- 
oped, unless some serious condition like pneumonia is 
about to occur. Other symptoms of this general strep- 
tococcic infection are: a diminished amount of lochial 
discharge, perhaps even without odor ; more or less 
tenderness in the pelvic region ; a coated and perhaps 



PUERPERAL INFECTION 529 

dry tongue ; bad, perhaps septic, breath ; scanty urine ; 
severe lumbar pains ; tympanites ; at times yellowing of 
the skin, and later, if the infection progresses and 
becomes serious, possibly delirium. The progress of 
the fever is that of a typical septicemia. There may 
be irregular chills, profuse sweatings and more or less 
leukocytosis. If the lungs, breasts, kidneys and throat 
have been excluded as the location of the cause of the 
temperature rise and onset of symptoms, and if the 
uterus is tender and enlarged, as it generally is, acute 
puerperal streptococci infection is in evidence. 

The insistence here should be on the fact that 
because there is a septic puerperal infection, it is not 
forthwith an indication for a uterine curettage, or 
intra-uterine or vaginal douching or any other severe 
operation. The general treatment just outlined for a 
more localized simple puerperal pelvic infection should 
be carried out, with more or less tepid spongings to 
control the high temperature. The bowels should be 
freely moved each day, large amounts of water should 
be drunk and perspiration should be encouraged, 
though the body should be kept clean by frequent 
warm spongings and alcohol spongings. The outdoor 
treatment in Watkins' opinion is the most valuable 
remedy known as yet in the treatment of puerperal 
infection. The beneficial effects of that treatment in 
his cases have been very noticeable, especially as 
regards improvement in appetite, sleep, temperature 
and pulse. 

The heart may be stimulated by infrequent doses of 
strychnin, not more than 1/30 grain once in six hours, 
with caffein (perhaps best as coffee) twice in twenty- 
four hours, if no delirium is present. Camphor is 
another valuable cardiac and nervous stimulant and 
20 or 30 drops of the official spirit of camphor, given 
properly diluted once in four to six hours, is good 
treatment in these cases. In emergencies, one, two or 
three injections of a sterile ampule of camphor solu- 
tion in oil hypodermically at intervals of an hour will, 
at times, tide over cardiac depression. Alcohol may 
or may not be indicated, depending on whether or not 
the patient can take other nourishment. It should not 
be used as a stimulant, and the dose should not be 



530 PUERPERAL INFECTION 

large. Whether ergot or hydrastinin should be given 
must be decided in each case. The ergot will improve 
the tone of the circulation, but may cause the uterus 
to contract more than is desirable. Digitalis should not 
be used except, perhaps, early in the disease, as the 
inflamed or injured myocardium which results from 
an infection must not be hurt by the strong contrac- 
tions which are caused by this drug. 

Fowler's position should be maintained to promote 
drainage, often with the use of uterine retention tubes, 
and the Murphy drip may be advisable. 

The diagnosis of a streptococcic infection having 
been made, the choice of one or more of the following 
specific treatments are available: 

1. Antistreptococcic serum. 

2. A stock streptococcic vaccine. 

3. An autogenous vaccine developed from the uter- 
ine secretion, 

Antistreptococcic serum has in some hands shown 
wonderful results ; in other hands it has failed. It 
should be used, if at all, in large doses, as it does not 
seem to do any harm. It often, however, is not at all 
antitoxic to the bacterial infection from which the 
patient is suffering. 

If vaccines or bacterins are to be used, they should 
be used early, and the stock vaccine selected must 
be polyvalent, that is, it must represent several strains 
of streptococcus, with the hope that one of them will 
be the one that has infected the patient. Later, these 
vaccines are not valuable, as then enough of such 
stimulation is going on in the patient. Therefore, 
in the advanced or later stages of the infection an 
antistreptococcic serum, if it were antitoxic to the 
germ from which the patient is suffering, would be 
of great value. 

If an autogenous vaccine is to be used, it should be 
produced early in the infection (such a bacterin, in 
emergencies, can be developed in from eighteen to 
twenty-four hours) and immediately given. More 
than one or two repetitions of such an autogenous vac- 
cine at twenty-four-hour intervals would be doubtful 
therapy, as in an acute infection such as puerperal 
septicemia the blood is soon producing all of the anti- 



PUERPERAL INFECTION 531 

bodies that it can. This is a very different process 
from a slow-going acute or chronic infection in which 
revaccinations are often of great value. 

As these infections are not malarial, unless a 
malarial germ is discovered in the blood, there is no 
excuse for administering quinin. If the diet is without 
meat, iron should be given, and is, perhaps, best 
administered in 5-drop doses of the tincture of ferric 
chlorid in fresh lemonade, given three or four times in 
twenty-four hours. Also the need of the body for lime 
should not be forgotten and simple lime-water may 
be used, or calcium glycerophosphate, in powder, in 
0.3 gm. (5 grain) doses, three times daily. 

If more or less serious uterine hemorrhage occurs, 
or if the discharges from the vagina are exceedingly 
fetid, showing decomposition products in the uterus, 
it may be necessary to institute some operative inter- 
ference. Perhaps the safest procedure is to administer 
an anesthetic and to explore and clean the uterus with 
the finger properly protected. Curettage of an infected 
uterus is serious and may cause serious results, to say 
nothing of the danger of perforating the softened uter- 
ine wall. It may be repeated that except for serious 
hemorrhage it is probably rarely advisable to clean out 
the uterus during septic infection. Decomposition will 
generally cause a loosening of foreign and pathologic 
tissues from the walls of the uterus, and they will 
generally be passed out through the vagina. Also, it 
should be remembered that in this septic infection the 
uterine muscle itself is more or less inflamed and 
softened, and contains, as well as the surrounding 
lymphatics, more or less of the infecting germ. Also, 
when the infection is well in progress the bacteria 
are probably in the blcod. Severe local measures, 
therefore, do not eradicate the disease and may open 
up other avenus of absorption. It may even be wise, 
in the presence of uterine hemorrhage, to pack the 
vagina first to see if the loosening membrane or piece 
of placenta will come away without actual uterine 
interference. 

It should be urged that intra-uterine injections 
and douches are rarely, if ever, indicated, are gen- 
erally dangerous and may do serious harm. Vaginal 



T 

532 PUERPERAL INFECTION 

douches in septic infection, while not so dangerous, 
may also cause harm and should generally be omitted. 
In other words, the pressure in the uterine and vaginal 
cavity should always be negative to the pressure on the 
other side of the blood-vessels and lymph-vessels to 
promote exudation into the parturient canal rather 
than absorption from this canal. There is danger, 
also, in intra-uterine injections of forcing septic mat- 
ter into the fallopian tubes. If, later, a pelvic mass 
is found, whether hematoma or abscess, hot vaginal 
douches may be allowable and of value in promoting 
absorption or in hastening localization for vaginal inci- 
sion and evacuation. 

If there is more or less peritoneal inflammation 
and, therefore, pain, morphin is indicated, as a 
patient should not be allowed to suffer pain, for 
depression from acute pain may be the last straw to 
stop an already weakened heart. Local applications to 
the lower part of the abdomen in the shape of turpen- 
tine stupes or alcohol fomentations may sometimes be 
of value as counterirritants. Warm applications, as 
flaxseed or poultices, may give some comfort and pre- 
vent the necessity of giving much morphin. They 
often cause a relaxation of the muscular tissues and 
lessen the irritation and tension. Of course such 
treatment is purely symptomatic and entirely non- 
specific. If serious infective localization occurs in the 
pelvis, more serious operative interference may be 
necessary. 

In recovery from this very dangerous infection the 
convalescence is long and tedious, and months generally 
elapse before there is a return to normal health. 

SUMMARY 

Hirst, Dickinson and De Lee, constituting a commitee 
appointed by the Section on Obstetrics, Gynecology 
and Abdominal Surgery, of the American Medical 
Association, reported (Jour. A. M. A., 1914, Oct. 25) 
to investigate the treatment of puerperal fever, sent 
out a series of questions to surgeons and obstetricians, 
in this country and abroad, covering the principal 
exigencies liable to be encountered in puerperal infec- 
tion. These replies to the questionaire give a definite 



PUERPERAL INFECTION 533 

idea of the practice of the respondents and fairly 
represent the best prevailing views obtainable, and in 
forming their conclusions due weight was given them. 
The conclusions deduced from the inquiry are given as 
follows: "The majority of accoucheurs and surgeons 
clean out the septic uterus at once, but a not negligible 
minority believe it is safe to trust the expulsion of the 
infected uterine contents to the powers of Nature, 
some assisting the same by mild measures such as 
antiseptic douches and packing. From this it is fair 
io infer that, in the majority of cases, it has been found 
jafe to invade the infected uterus with finger and 
(uret, and this is borne out by experience. There are, 
lowever, many cases in which the infection is of such 
i nature, or the resistance of the patient of so poor 
c quality, that the sudden introduction into the system 
(f so large an amount of bacteria and toxins as is 
dways made by curettage, turns the scale against the 
ptient. She cannot stand the inoculation with auto- 
genous vaccines. The experience of the minority has 
p-oved that ovular remnants, even though infected in 
tie uterus, do not create such dangerous conditions as 
re formerly believed, demanding instant removal, but 
tlat it is safe to wait for Nature to erect her own bar- 
rfer against the progress of the infections, and that 
terrorizing measures or mildly stimulating ones often 
siffice for cure. We all feel the need of some method 
b} which it would be possible to distinguish benign 
fnm virulent bacteria living in the genitalia, but as 
ye no such method exists. When it does become 
pGsible, our practice will become more definite. At 
prsent one-half of the authorities do not try to make 
th' distinction, holding it impractical. One point that 
ws almost invariably emphasized was that after the 
utrus was once emptied it should not again be invaded 
by either finger or curet. Few would permit anti- 
sejtic douches. This is a very grateful change from 
thctime when repeated curettages were performed on 
the puerperal uterus — a procedure which was as 
ratonal as curetting the throat in diphtheria. Another 
intresting fact that has developed is that quite gen- 
eraly the tampon is used to stop the bleeding in 



534 POSTPARTUM HEMORRHAGE 

infected cases. Evidently there is not much fear of 
damming back the infection and permitting greater 
absorption/' 

POSTPARTUM HEMORRHAGE 

This subject was fully considered several years 
ago in a symposium in the New York Medical Journal 
The facts there brought out are basic however, and 
worthy of frequent repetition. 

ETIOLOGY 

The causes in general may be summed up as : Those 
which interfere with uterine contractions or cause 
relaxation of the uterine muscle ; lacerations of the 
parturient canal, and partial or complete retention o: 
the placenta. The management of the condition pre- 
sents practically nothing new, viz : Administration of 
ergot ; removal of uterine contents ; repairs of lacei- 
ations ; massage of the uterus ; hot intra-uterire 
douches ; packing the uterus. 

PROPHYLAXIS 

Avoid precipitate labors. Avoid protracted labois. 
Avoid a surplus of anesthesia in slow labors ; chloial 
(one gram, repeated in an hour if necessary) is prefer- 
able. If there is history of hemophilia, give calciim 
chlorid for three months prior to delivery. At tie 
onset of labor see that the bladder and rectum rre 
empty, and as soon as the head is born ergot shoild 
be given (preferably by the hypodermic syringe), cid 
the fundus massaged to stimulate contractions. lit- 
uitary extract may be given cautiously. 

If hemorrhage begins during the period between he 
birth of the child and the expulsion of the place:ta, 
and without evident relaxation of the uterus, it ma] be 
due to a partial separation of the placenta or to the 
fact that the placenta is separated but still withinthe 
uterus. 

TREATMENT 

Hemorrhage immediately following the birth ofthe 
child may be from the circular artery of the cerix ; 
from a lacerated vagina, or from a lacerated perinum. 



UTERINE HEMORRHAGE 535 

In such cases, with the use of the speculum and a con- 
stant stream of water to wash away the flowing blood, 
immediate repair of the laceration is usually easy, and 
correctly placed stitches will stop the hemorrhage. 

If the bleeding does not amount to much more than 
oozing, swabbing with epinephrin solutions may be 
effective. 

The Crede method of expulsion of the placenta will 
usually stop the flow by removing the obstacle, and will 
stimulate the uterus to contract. Failing thus to 
remove the placenta, the necessity of manual removal 
should be considered. 

The placenta having been born, if the hemorrhage 
continues and the uterus is soft and flabby, contraction 
of that organ is the end aimed at. This may be 
secured by continued manual stimulation from without 
and the use of pituitary extract. 

If the hemorrhage still continues, Bryan, Philadel- 
phia, advises the "bimanual manipulation/' usually 
accomplished "by passing two fingers of the right hand 
high up into the vagina, along the posterior wall, press- 
ing the lower segment and cervix forward toward the 
symphysis pubis, at the same time passing the finge r s 
of the left hand deep in between the umbilicus and the 
uterus so that the hand on the outside, the fundus rest- 
ing in the palm of his hand, may be pushed downward 
and forward against the pubes, thus forming a sort of 
temporary anteflexion. " 

When* these methods fail, the next thing to do is to 
pack the uterus. The volsella forceps are preferable 
for this, as there is little danger that the cervix will 
contract so as not to admit them, and the ordinary 
uterine dressing forceps are sharp enough at their 
points to admit an element of danger from the pos- 
sibility of their being pushed through the fundus. The 
packing may remain in the uterus for from six to 
twenty-four hours, and when it is removed another 
packing should be ready to replace it, if necessary. 

UTERINE HEMORRHAGE 

The causes of uterine hemorrhage are numerous and 
must be ascertained before actually scientific treatment 
may be undertaken. 



536 CAUSES OF UTERINE HEMORRHAGE 

ETIOLOGY 

It appears desirable to Whitehouse, (Lancet, 1914, 
April 4, p. 950) that a careful investigation of the 
discharge should be made in every case of obscure 
uterine bleeding. The points in the investigation to 
which special attention should be directed are: 1. The 
presence or absence of thrombi within the vagina. 
2. The formation of thrombi within the discharge 
after the fluid has been allowed to stand. 3. The 
thrombolytic power of the secretion. 4. The calcium 
content of the same. 5. The microscopic characters 
of the deposit obtained after centrifugalization of the 
fluid collected directly from the uterine cavity in order 
to obtain an index of the degree of tissue destruction. 
Six hundred and eight cases were analyzed by White- 
house. 

It was evident that displacements of the uterus 
do not directly produce excessive uterine hemorrhage. 
In cases in which hemorrhage was present it was not 
shown that the displacement was more acute than. in 
patients in whom no bleeding was present. On the 
other hand the proportion of irregular bleeding was 
considerably greater in the complicated cases than in 
those that are simple. With prolapsus uteri it was 
found that but few cases showed evidence of excessive 
bleeding. 

Fibrosis and chronic nephritis was in a very large 
proportion of cases associated with uterine bleeding. 
Hemorrhage in cases of fibrosis uteri is probably due 
to two factors: (a) changes in the endometrium, and 
(b) loss of contractility of the metrium owing to its 
replacement by fibrous tissue. Out of a total of 
seventy-three cases of endometritis fifty-six were asso- 
ciated with menorrhagia and twenty-nine with metror- 
rhagia. A thorough investigation of the cases classed 
clinically as "endometritis" showed that sixty-one of 
the patients were married, and of these forty-three 
directly attributed the irregular hemorrhages to the 
last labor or abortion at intervals varying from three 
months to one year. The irregularity, in fact, dated 
from the resumption of function. Examination of 
the curettings revealed the following facts: (a) 
twenty-five cases showed what in the past was desig- 



CAUSES OF UTERINE HEMORRHAGE 537 

nated "glandular endometritis'' ; (b) nine cases showed 
all the characteristics of the so-called "interstitial 
endometritis" of Ruge's classification; (c) atrophic 
"endometritis" was present in two; (d) plasma cells 
and marked leukocytic infiltration appeared in seven. 
In other words, thirty-four exhibited only evidence of 
those changes known to be but physiologic, and there- 
fore could not be classed as "endometritis." Endo- 
metritis of septic origin does not appear to produce 
uterine hemorrhage. 

Hypertrophy of the endometrium, in its diffuse 
form, occurs under the name of "glandular hyper- 
trophy" ; its localized variety is the common "adenom- 
atous polypus." Hemorrhage is usually profuse and 
appears to be due to excessive thrombolysis of the 
uterine clot. Cystomata of the ovary rarely cause 
interference with the menstrual function. Displace- 
ments of this organ as a general rule do not produce 
excessive uterine hemorrhage. Hypertrophy of the 
ovary affects the stroma rather than the Graafian 
follicles, and the close association of the condition 
with hypertrophy of the endometrium appears to 
afford clinical evidence that it is from the ovarian 
stroma that the specific hormone is derived. 

Pelvic inflammation is not infrequently associated 
with excessive hemorrhage from the uterus. White- 
house is inclined to think that the hemorrhage is the 
result of interference with venous return rather than 
to any specific effect either on endometrium or ovary, 
since it occurs not only in connection with inflam- 
matory lesions related to the sexual organs, but also 
in cases secondary to extragenital inflammation, such 
as appendicitis. 

The value of curettage in the therapeutics of uterine 
hemorrhage Whitehouse says is principally for diag- 
nostic purposes. If the examination of the curetted 
endometrium is taken in conjunction with an analysis 
of the menstrual discharge, and care taken to correlate 
the appearances of the endometrium with the period 
of the sexual cycle, much valuable information may 
be gained as to the cause of a specific hemorrhage. 
Curettage at the two extremes of sexual life is, in 
his opinion, a useless procedure except for diagnostic 



r 



538 TREATMENT OF UTERINE HEMORRHAGE 

purposes. It is not possible to alter the character of 
the endometrium by any amount of curetting. This 
is proved by examination of repeated curettings from 
the same uterus, and it accounts for the fact that in 
glandular hyperplasia of the endometrium curettage 
is only of temporary benefit. 

TREATMENT 

A summary of recent views as to the treatment of 
uterine hemorrhage yields universal agreement as to 
the necessity of making every endeavor to treat the 
cause. 

Adler (Med. Klinik, 1914, x, p. 183) believes that 
palliative measures should never be applied in the 
treatment of uterine hemorrhage until after malignant 
disease has been positively excluded. With extra- 
uterine pregnancy, the course is generally either that 
after a normal menstruation of the ordinary four-day 
type the following menstruation is retarded several 
days and then extends over a week or more, or it may 
occur a few days before the regular period and keep 
up for two weeks or more, or it may commence at the 
regular period but keep up for a long time. The 
hemorrhage is less profuse than at an ordinary menses 
but it keeps up for days and weeks without interrup- 
tion, and there is slight discomfort or pain in the side 
of the abdomen. Conservative treatment is entirely 
out of the question when extra-uterine pregnancy is 
once certain, he declares. His research has confirmed 
the assumption that endometritis has nothing to do 
with uterine hemorrhage ; the uterus proper is seldom 
responsible for the hemorrhage ; the ovaries or reduced 
coagulating power of the blood, the effects of con- 
stipation, tight lacing, a sedentary mode of life, 
abnormal sexual excitement or emotional stress are 
more likely to be the factor or factors involved, induc- 
ing irregular menstruation or prolonging and exagger- 
ating normal menses. Local treatment of the uterus 
has therefore lost ground in favor of causal measures ; 
the curet has lost its vogue since it has been shown 
that it had a curative influence in only 10 per cent, of 
500 cases of uterine hemorrhage compiled by Busse. 
Mere bed rest alone may control uterine hemorrhage 



THERAPY OF UTERINE HEMORRHAGE 539 

in women nearing the menopause and in young girls. 
In other cases a change of climate by improving the 
general health has cured the tendency to hemorrhages. 
Out-of-door life at a moderate altitude, saline and 
chalybeate baths may prove useful while mud baths 
often have a directly injurious action. Keeping the 
bowels open by proper dieting is of the greatest 
importance. 

CURETTAGE 

As reiterated by Whitehouse, Adler and many 
others, the use of the curet in the treatment of uterine 
hemorrhage is losing vogue. If bleeding is due to 
excessive thrombolysis, the result of hyperplasia of 
the endometrium, temporary relief may be obtained, 
however, by curetting. Curetting helps in some cases, 
perhaps, by inciting the uterus to vigorous contractions, 
which put an end to venous stasis by which the hemor- 
rhage may have been maintained. 

BLOOD, SERUM AND FERMENTS 

Where hemorrhage is due to the absence of thrombo- 
kinase attempts may be made to replace the same. 
Fibrin ferment directly applied to the endometrium is 
also of service in directly checking hemorrhages of this 
nature. Curtis (Jour. A. M. A., Jan. 23, 1915, p. 332) 
found that repeated subcutaneous injection of whole 
blood immediately on a withdrawal from a healthy 
donor, obviated the need of further treatment in 
many cases of uterine hemorrhage. 

ROENTGEN THERAPY 

The Roentgen rays have proved useful in the treat- 
ment of bleeding myomas. Adler says it must be 
continually borne in mind that they act only on one 
symptom, the hemorrhages ; the symptoms from trac- 
tion by adhesions or pressure on adjacent organs are 
not influenced, and the danger of cancer is present 
in from 5 to 10 per cent, at least of all cases of uterine 
myoma. If roentgenotherapy is applied it should be 
only under the constant control of the gynecologist. 
Adler remarks of radium treatment that the dangers 
from it are so great and it is so impossible to reckon 



540 TREATMENT OF UTERINE HEMORRHAGE 

with them beforehand, that this method of treatment 
cannot even be suggested for uterine hemorrhage. 

MEDICAL TREATMENT 

According to Thielhaber (Archiv. f. Gynak., 1914, 
No. 1, abstr. Jour. A. M. A., 1914, March 21, p. 972), 
tonics and calcium may be given. Ergot often is 
beneficial, taken before and during the menses, keep- 
ing this up for months. Local injection of ergot or 
hypophysis extract may also help in arresting a hemor- 
rhage. Systematic scarification in the period preceding 
the menses has also rendered good service in his and 
Fiith's experience. He has applied cauterization about 
25,000 times, during the last thirty years, and has never 
had a serious mishap with it. He regards acute and 
subacute gonorrhea as a contraindication, but has 
applied the caustic a number of times in chronic gonor- 
rhea when it has kept up for a year or two. He used 
to apply a 30 per cent, solution of zinc chlorid, but has 
lately changed to a 30 per cent, solution of formal- 
dehyd, applying it on a cotton-wound sound. 

Gerstenberg (Zentralbl. f. Gynak., 1914, xxxviii, 
p. 1201) uses a solution containing 40 parts formal- 
dehyd. in 60 parts of water to paint the uterine mucosa 
to arrest climacteric hemorrhage, and has never had 
any mishaps with it. It advantageously substitutes 
for or supplements curetting or roentgenotherapy 
while it is far superior for numerous reasons to 
atmocausis or zinc-chlorid applications. He even 
affirms that if uterine hemorrhage in women of 40 
to 50 is not arrested by two formaldehyd applications 
in this way, some special cause for the hemorrhage is 
more than probable. 1'he trouble generally proved 
to be myoma in his cases ; in one the myoma prevented 
the formaldehyd from reaching the mucosa above it. 
He applies the formaldehyd for fifty seconds alto- 
gether and uses two sounds at once. 

Sehrt found pronounced hypofunction of the thyroid 
in numerous cases of uterine hemorrhage. Following 
the administration of the various preparations of 
thyroid, he found that not only the hemorrhages but 
the general health became markedly improved. 



DYSMENORRHEA 541 

Focke has called attention to the fact that in uterine 
hemorrhage without organic basis digitalis is of great 
aid in addition to local measures which are applied. 

It is particularly useful in hemorrhage during a 
pregnancy, and in recurring menorrhagia in the young 
and in the elderly; in short, in all cases in which the 
uterus is apparently sound and some disturbance in 
the circulation causes a tendency to transient con- 
gestion and spontaneous (essential) bleeding. He has 
prescribed digitalis for uterine hemorrhages in 100 
cases during the last fourteen years and here analyzes 
fifty of them. When the uterus was diseased there 
was not much effect from the drug, but it proved 
invariably effectual in his twenty-nine cases of exces- 
sive or too frequently returning menstrual hemorrhage. 
In these cases he commences the digitalis a week before 
the anticipated menstrual period. 

DYSMENORRHEA 

The treatment of dysmenorrhea should, of course, 
vary with the indications as based on the underlying 
condition. Cases should be analyzed as to the exis- 
tence of defective development of the genital organs, 
abnormal ovulation ; in some cases the cause must be 
sought in the glands of internal secretion, especially 
the thyroid ; in some instances, dysmenorrhea is asso- 
ciated with puerperal bradycardia and arrhythmia. The 
condition known as vagotony may be at the basis of 
the menstrual pain or local or radiating neuralgias 
may be responsible. In still another class of cases 
spasmodic contraction is the source of pains ; defective 
development of the uterus may be the basis for this or 
it may be maintained or aggravated by pain in the 
ovaries. The spasm may be more painful when there 
is any mechanical hindrance to distention of the ovaries 
and uterus during menstrual congestion. 

Mosher believes that dysmenorrhea is largely a 
functional disorder, congestive in type and produced 
by (1) the upright position; (2) alteration of the 
normal type of respiration by disuse of the diaphragm 
and of the abdominal muscles; (3) the lack of gen- 
eral muscular development; (4) inactivity during the 
menstrual period; (5) psychic influences. She shows 



542 CAUSES OF DYSMENORRHEA 

how the upright position with the valveless vena cava 
causes uterine congestion which tends to become exag- 
gerated when the abdominal muscles are lax, when 
costal breathing is employed and by clothing, which 
interferes with the action of the respiratory muscles. 
Mosher has corrected these conditions in many cases 
by the following method : "All tight clothing having 
been removed, the woman is placed on her back, on 
a level surface, in the horizontal position. The knees 
are flexed and the arms placed at the sides to secure 
relaxation of the abdominal muscles. One hand is 
allowed to rest on the abdominal wall without exert- 
ing any pressure to serve as an indicator of the 
amount of movement. The woman is then directed to 
see how high she can raise the hand by lifting the 
abdominal wall; then to see how far the hand will 
be lowered by the voluntary contraction of the abdom- 
inal muscles, the importance of this contraction being 
especially emphasized. This exercise is repeated ten 
times, night and morning, in a well-ventilated room, 
preferably while she is still in bed in her night-cloth- 
ing. She is cautioned to avoid jerky movements and 
to strive for a smooth, rhythmical raising and lower- 
ing of the abdominal wall/' The results have been 
that the pain has been lessened in many cases and 
wholly removed in a large number. The desirability 
of more activity is noticed but she cautions against 
excess, especially in the athletics of college training. 
A hopeful mental condition is important, and it is 
unfortunate that pain or disability is so commonly 
expected. 

In those types of dysmenorrhea due to vagotony, 
when the autonomic nervous system is in a state of 
hypertonicity, the pronounced spasticity from over- 
stimulation of the vagus brings on pain at menstrua- 
tion and atropin wards this off or cures it. In small 
doses atropin has a stimulating and in large doses 
a paralyzing action on the sympathetic nervous sys- 
tem, and instances of failure to relieve the dysmenor- 
rhea are probably due to incorrect dosage. Atropin 
arrests the pains by paralyzing the nerve terminals 
belonging to the vegetative nervous system. The 
menstrual discharge increases in amount after taking 



TREATMENT OF DYSMENORRHEA 543 

the atropin, possibly from relaxing the spasmodic 
contraction of the vessels or of the uterus or both. 
Papaverin also has a paralyzing action on the smooth 
muscles, and may prove useful in combating dysmen- 
orrhea. On account of danger of hemorrhage from 
atony of the uterus, atropin is necessarily contra- 
indicated when abortion or delivery is once under way 
and there is considerable uterine hemorrhage. 

In a certain proportion of cases Stolper found 
atropin ineffectual. In every one of these there was 
a blood pressure higher than normal. If the blood- 
pressure is abnormally high there seems to be no use 
in giving atropin ; treatment must be directed to 
reducing the blood-pressure, and cause must be sought 
and removed. It very frequently is found in the 
pelvis, a tumor or inflammation in one of the genital 
organs or chronic constipation causing local disturb- 
ance in circulation. When the cause is removed the 
blood-pressure becomes normal and the dysmenorrhea 
either is conquered or then becomes amenable to 
atropin. 

Dalche {Revue Mens, de Gyn., d'Obstet. et de Fed., 
1914, viii, p. 641) discusses the use of thyroid and 
ovarian extract in dysmenorrhea. He believes that 
when no definite cause may be found a course of 
thyroid treatment may restore the balance between the 
internal secretions. He has frequently found it effec- 
tual in regulating menstruation, increasing the menses 
to normal proportions and without abnormal pain. He 
gives small doses of pulverized thyroid, 0.025 to 0.05 
or even 0.1 gm. a day, keeping this up for a month or 
more to get the full benefit of its stimulating and regu- 
lating action on the functioning of the ovaries. The 
patient must be kept under close supervision during 
the course, suspending the organotherapy if the pulse 
goes over 100, or at least materially reducing the dos- 
age. After the first month he has the thyroid treat- 
ment continued only during the ten days preceding the. 
date of menstruation. Sometimes he has found it 
better to alternate ovarian and thyroid treatment, thy- 
roid in the morning and ovarian tissue at evening, or 
giving the ovarian treatment continuously for three 
days and then the thyroid continuously for the same 



544 STERILITY IN WOMEN 

length of time and then resuming the ovarian treat- 
ment. 

He has never had any mishaps with this treatment 
and has been more successful with it than ever before 
in the management of dysmenorrhea. The only disad- 
vantage is that it generally has to be kept up for 
months or resumed occasionally to obtain durable 
improvement or a complete cure. 

GENERAL TREATMENT 

To relieve the pain during dysmenorrhea, a rectal 
enema of sodium bromid may be given. Dalche uses 
laudanum and antipyrin in small dosage as a rectal 
enema, the ratio being 10 of laudanum to 1 of anti- 
pyrin. Relief may be obtained from hot applications 
on the feet, front of the legs and inner side of the 
thighs, with moist heat t.o the abdomen. Sedative 
liniments and pomades may also prove useful or even a 
blister. The patients should guard against constipa- 
tion, lead a quiet life and keep in bed during the men- 
strual period. It is a frequent experience that if by 
vigorous means it is possible to ward off the pain with 
menstruation once, twice or three times in succession, 
the tendency to dysmenorrhea seems to be broken up 
and menstruation proceeds normally thereafter. 

STERILITY IN WOMEN 

The treatment of sterility has, according to Reynolds 
(Jour. A, M. A., Oct. 11, 1913, p. 1363), long been 
one of the comparative failures of gynecology and he 
has been struck with the frequency with which women 
sterile to normal husbands have nevertheless been 
pronounced normal themselves, even by recognized 
authorities. He has seen this repeatedly in cases where 
in his opinion a fully adequate cause existed in the 
genital organs, treatment of which resulted in prompt 
fertility. The causes of sterility in women may be 
classified under two heads : Disorders of the secretion 
of the genital mucosa which are destructive to the 
continued life of the ova or spermatozoa or annul the 
active motility of the latter ; second, conditions in the 
ovaries inhibiting the formation of the ovum or pre- 
venting its release at maturity. The normal secretion 



CAUSES OF STERILITY IN WOMEN 545 

may be altered by disease or there may be fermenta- 
tive or other changes in the secretion given out by a 
normal mucous membrane. It is only by close obser- 
vation of these secretions that the cause of the sterility 
can in these cases be discovered. A secretion of any 
one of the parts of the genital tract is most likely to 
be harmless to those above it, but an alteration of an 
upper secretion almost necessarily implies a similar 
abnormality of the secretions below into which it 
passes. Secretions in the patent vagina are rarely abso- 
lutely normal, but the importance of the condition must 
be estimated differently in the nulliparae, who form 
most of the subjects of sterility, and in the multiparae. 
A cause efficient against conception in the former may 
have no effect in the latter, owing to the slightly alka- 
line secretion of a lacerated cervix and the greater 
facility of the entrance of the spermatozoa. The most 
common causes of the alterations of the cervical secre- 
tion alone are retention and consequent thickening of 
the secretion behind a pinhole os. As regards the 
uterine secretion, which largely depends for its nor- 
mality on the free drainage, so long as it is thickened, 
clouded, mucopurulent or seropurulent, there will be 
no pregnancy. It is not generally realized that the fal- 
lopian tubes have a secretion, but this must be inferred 
from their structure. Remembering that they are mor- 
phologically a part of the uterus it would seem it must 
be so. Reynolds considers that besides a regular sal- 
pingitis there may be many minor conditions which 
might affect the tubal secretion. The existence of 
ovarian infertility has long been accepted as possible. 
The alterations that are most common in sterility 
cases are slight to moderate enlargements caused either 
by the presence of numerous small to medium sized 
retention cysts, or of unduly large, persistent, and fre- 
quently cystic corpora lutea. The claim that bilateral 
enlargement of the ovaries by retention cysts is a cause 
of sterility cannot at present be proved, but the impor- 
tance of persistent corpora lutea is better established. 
He has in his records cases of this kind and veterinary 
practice has recognized it in cows. As regards treat- 
ment the alterations of the vaginal secretion are appar- 
ently always due to infection, with the exception of 



546 ASPHYXIA NEONATORUM 

profuseness, from general pelvic congestion or of those 
hyperacidoses from a general constitutional acidosis. 
Treatment naturally follows along the lines indicated 
by these etiologies. In alterations of the cervical secre- 
tions we should include the ordinary typical applica- 
tions and perhaps curetting, but always the complete 
drainage of the cervical cavity. Any constriction 
should be done away with by operation if necessary. 
The only two methods of treating the uterine mucosa 
needing mention are curetting and disinfection and 
these are difficult to perform with thoroughness. Com- 
plete drainage by plastic work if necessary is essential 
and mere dilatation is inefficient. At the base of the 
whole subject lies the principle that even the ovarian 
infertilities are almost invariably associated with physi- 
ologically obstructive conditions, minor or major, and 
the patency of the genital canal is only that of its most 
obstructed point. This is not the mere mechanical 
patency, but that more complicated physiological 
patency allowing the conjugation of the germs and 
the subsequent growth which may be affected by such 
minute alterations that they escape diagnosis under 
merely routine observation. 

ASPHYXIA NEONATORUM 

This condition is one which every obstetrician should 
be prepared to treat promptly. In milder degrees it 
occurs in a large proportion of deliveries. In its more 
severe forms it fortunately is less common. 

The more common causes of the condition are pre- 
mature detachment of the placenta, prolapse of the 
umbilical cord, excessive use of chloroform, of chloral, 
or of morphin administered to the mother to diminish 
the pain of labor, or large doses of ergot given during 
the second stage of labor to increase the contraction of 
the uterus, extreme compression of the head of the 
child ow T ing to the unusually severe contractions of the 
uterus separated by brief intervals, obstruction to the 
passage of the head by narrowness of the pelvis, com- 
pression of the head by unskilled delivery with for- 
ceps, compression of the after-coming head in the 
delivery of breeches cases, and compression of the cord 



ASPHYXIA LIVIDA 547 

through its being wound around the child's neck, or 
through its being drawn into a knot. 

PREVENTION 

The preventive treatment naturally is based on a con- 
sideration of these causes. In instrumental delivery 
great pressure on the head of the child should be 
avoided, and the traction should be made intermittent 
and not continuous. If there is prolapse of the umbili- 
cal cord, it should be replaced, the woman placed in 
the knee-chest position, and every effort made to 
retain it until the head has become engaged in the brim 
of the pelvis. In all severe labors preparation should 
be made before the birth of the child to apply suitable 
treatment in case it should be born in a condition of 
asphyxia. These preparations should include a baby's 
bath tub with a supply of warm water conveniently at 
hand, a bowl of cold water, a warm woolen blanket, 
a small piece of gauze, and a hypodermic syringe. 

As soon as the child is born it should be promptly 
slapped repeatedly on the buttocks and back. The 
mouth and throat should be wiped out with a piece of 
gauze so as to clear out any blood, mucus or amniotic 
fluid which may be there. If this does not promote the 
reflex action of breathing, the cord should be felt to 
see if it is pulsating. 

By this time one has had an opportunity to inspect 
the surface of the child to see whether the condition is 
one of asphyxia livida, in which the skin is congested 
and livid and the reflexes are maintained ; or whether 
the condition present is asphyxia pallida, in which the 
surface is pale and cold, the muscles are relaxed, and 
the reflexes are absent. The treatment should vary 
somewhat according to which of these two conditions 
is present. 

ASPHYXIA LIVIDA 

If the condition is one of asphyxia livida, with con- 
gestion of the skin, there is some difference of opinion 
as to whether the cord, if it is pulsating, should be at 
once cut and a small amount of blood allowed to escape, 
or whether it should not be cut until later. Probably 
it is wiser to postpone this for five or ten minutes. In 
the meantime the child should be grasped by its feet 



548 ARTIFICIAL RESPIRATION 

in the left hand of the physician and held in an inverted 
position while several light blows are administered on 
the buttocks, shoulders and chest, in order, if possible, 
to expel any more blood or mucus which may be in 
the larynx and trachea. This position should be main- 
tained for only a few seconds. 

ARTIFICIAL RESPIRATION 

Next, the Byrd Dewey method of artificial respira- 
tion should be tried. This consists in placing the palm 
and fingers of the right hand under the child's shoul- 
ders, while the index finger and thumb support its 
head, the left hand being placed under the hips. With 
the child in this position, by raising the radial sides* 
of the hands, the legs and knees of the child are 
brought up onto its chest and the chest is compressed 
so that the air is expelled ; then reversing this position 
and allowing the head and shoulders to fall backward, 
the chest is expanded and the air drawn in. These 
meneuvers should be repeated at intervals of about 
five seconds, so that the procedure will be repeated 
from ten to fourteen times in a minute. If the cord 
is of average length, this can be done before the 
cord is cut. 

If the cord has not been cut before, it should be 
now, and the child at once placed in a tub in which 
water of a temperature between 100 and 105 F. has 
been placed. This will promote the circulation in the 
skin and prevent the body from being chilled, and 
further treatment may be carried out. 

The next method of encouraging respiration is that 
known as the method of Laborde. This consists in 
grasping the tip of the tongue either with the thumb 
and finger, with the aid of a piece of gauze, or with 
forceps, and drawing it forward and then letting it fall 
backward. This should be repeated from ten to four- 
teen times a minute, and may be continued for one or 
two minutes. While this is being done the child should 
lie with the head drawn slightly backward, or on 
one side. 

If the child does not breathe by this time, it is 
well to take it out of the warm water and plunge it 
into a bowl of cool water of a temperature of from 



TREATMENT OF ASPHYXIA 549 

65 to 75 F. It should be allowed to remain here but 
a few seconds, and then placed back in the warm 
water. In the meantime it should be vigorously 
rubbed, but at the same time caution should be used 
not to rub it harshly for fear of doing serious damage 
to the skin. 

In some cases it has been found that inserting the tip 
of the little finger into the anus will stimulate the reflex 
action of breathing. 

Another method not infrequently employed is that 
known as the method of Schulze, which consists in 
standing back of the child, placing the palmar surfaces 
of the three outer fingers under its shoulders, the index 
finger of each hand under the axilla, and the thumbs 
on the chest, with the ball of the thumb resting on each 
side of the child's head. The physician thus grasping 
the child and then standing erect, gradually swings the 
child forward and upward in front of himself until it 
is above his head. In this position the child's thighs 
and legs fall against its chest, which is thereby com- 
pressed and the air forced out. Then swinging the 
child back into the original position, the chest is 
expanded, and the air enters. This may be repeated 
at intervals of five or six seconds, so that it will be 
done from ten to fourteen times in a minute. This is 
a method which presents more or less of the appear- 
ance of violence, and hence it is not always practicable 
to do it in the presence of the friends of the patient. 
It should also not be practiced if there are fractures 
of any of the bones, or if the child is especially feeble, 
or has been born prematurely. 

If difficulty has been experienced in clearing the 
larynx and trachea of mucus, a small soft catheter may 
be inserted through the larynx into the trachea, and 
any mucus present drawn out, either by the physician 
himself or with the aid of a syringe or aspirator. 

If other methods fail, it is recommended to blow air 
into the lungs of the child. This may be done by the 
so-called mouth-to-mouth method in which, a piece of 
gauze being placed over the mouth of the child, the 
physician filling his cheeks with air expels it into the 
mouth of the child, at the same time holding the 
child's nose. This method is somewhat inexact, as 



550 ASPHYXIA PALLIDA 

much of the air frequently goes into the stomach, but 
some of it goes into the lungs, if they are not already 
distended. After blowing air into the lungs, the chest 
should be compressed so as to drive it out again. 

An effective method of resuscitating asphyxiated 
infants is that of Meltzer and Auer, by tracheal insuffla- 
tion. A rubber catheter is passed into the trachea as 
far as the bifurcation and air is pumped into the lungs 
by means of a rubber bulb, the pressure being regulated 
by a mercurial manometer connected with the appara- 
tus. The return air escapes alongside the catheter. 

A few drops of ammonia on a piece of linen may be 
held under the child's nose, but not too closely, with 
the hope that this will stimulate respiration and, as it 
sometimes does, muscular contraction. A hypodermic 
injection of a drop of tincture of belladonna or 1/1,000 
of a grain of strychnin may be given. 

If by the time all these methods have been tried the 
child has not commenced to breathe, the physician 
naturally wonders how long he ought to continue his 
efforts. The answer to this question depends largely 
on the condition of the heart. He should continue his 
efforts at artificial respiration and external stimulation 
as long as the heart beats. After it has been impossi- 
ble for five minutes to detect any pulsation of the 
heart, it is useless to continue any further efforts at 
resuscitation. 

Jf the efforts have been successful and the child 
commences to breathe, even if the breaths are taken at 
long intervals, one should avoid an over-anxiety in 
interfering with the natural performance of the func- 
tion by the child. Once it has begun to breathe it prob- 
ably will continue to breathe and the breaths will 
increase in depth and frequency until they become 
normal. 

ASPHYXIA PALLIDA 

Turning now to the other class of asphyxia neo- 
natorum, viz., asphyxia pallida, in which the reflexes 
are absent and the heart is weak ; if the cord is not 
pulsating, it should be immediately cut and the child 
placed in a tub of warm water. If, however, it is 
pulsating the child should not be separated from the 
mother until the pulsation has ceased. The same 



ASPHYXIA PALLIDA 551 

methods are applicable in these cases as in the others, 
except that the more violent ones had better be omitted 
and all efforts concentrated on the employment of the 
milder methods, especially the rhythmical traction of 
the tongue as practiced by Laborde. Especially is it 
important to maintain the temperature of the child, 
and the water in the warm bath should be maintained 
at a temperature of 100 or a little higher by adding 
fresh warm water as fast as the water in the tub 
becomes cool. 

After the child has gained the ability to breathe 
regularly it should be carefully watched for several 
days, for if there has been difficulty in relieving the 
asphyxia, there is danger that it will become feeble 
and die in the course of a few days. It should be well 
wrapped up, and the external heat should be main- 
tained. The milk should be drawn from the mother's 
breast and fed to it with a medicine dropper, if it is 
not able to take hold of the breast and draw for 
itself. 



DISEASES OF INFANCY 



INFANT MORTALITY AND FEEDING 

The amount and extent of infant mortality have 
been estimated in various ways. In general, all seem 
to agree that approximately 15 per cent, of all chil- 
dren born die before they are 1 year old. As to the 
causes of fetal mortality, Williams (Jour. A. M. A., 
Jan. 9, 1915, p. 95) analyzed 705 fetal deaths 
which occurred in 10,000 consecutive admissions to 
the obstetrical department of Johns Hopkins Hospital. 
Included in this list are all those who died immediately 
after birth up to those who lived two weeks and died. 
Of this class syphilis was responsible for 26 per cent. ; 
unknown causes, 18 per cent. ; dystocia, 17 per cent. ; 
various unpreventable complications as hemorrhagic 
diseases, cord infection, status lymphatics, strangula- 
tion by loops of cord, about 11 per cent. ; prematurity, 
7 per cent. ; toxemia, 6.5 per cent. ; deformity, inani- 
tion, criminal suffocation, placenta praevia, etc., all 
less than 5 per cent. The cure for this type of infant 
mortality is proper prenatal care. This prenatal care 
means that the physician must examine his cases, make 
regular urine examinations, see that the expectant 
mother secures a proper diet, correct and sufficient 
exercise and a proper hygiene. 

Approximately one third of the deaths during the 
first year are due to congenital malformations, 
deformities and weaknesses ; another third to diarrheal 
diseases ; a little less than one fourth to respiratory 
and tuberculous diseases ; and the remainder to other 
diseases. 

It is toward the diminution of the number of deaths 
from diarrheal diseases that preventive efforts are con- 
spicuously directed. A very large proportion of these 
deaths occur during the hot weather, between July 1 
and October 1, and are directly traceable to improper 
feeding and improper food. Hence arises the great 
importance of the problem of feeding the infant. 



BREAST FEEDING 553 

When the fact is recalled that the milk of different 
animals varies in composition, it is not necessary at 
the present day, and in the present advancement of 
scientific knowledge, to enter on any argument to 
attempt to prove that the milk of the human mother 
is the very best food for the human infant during the 
early months of its life. Every woman, therefore, who 
gives birth to a living child, unless she is suffering from 
some serious disease, should nurse her child. This 
course is not only decidedly advantageous to the 
mother, but is also of the greatest importance to the 
child. 

BREAST FEEDING 

No artificial method of feeding has ever been devised 
which is as beneficial as nursing at the breast of a 
healthy mother. Unfortunately, many mothers object 
to performing this duty on various grounds ; some 
because they have sore nipples and nursing is painful ; 
others because the baby will not take the nipple, and 
therefore is given a bottle instead ; others because they 
think that their milk is not adequate in quantity or of 
sufficiently good quality to properly nourish the baby; 
others because they think that their health is being 
undermined by the drain on the system incident to lac- 
tation ; and still others because they are unwilling to 
give up social pleasure so as to be available to nurse 
the baby every two or three hours. All these condi- 
tions should be taken into account by the physician, 
and such as are present in any individual should, if 
possible, be removed. He should emphasize to the 
mother the great importance, both to herself and to her 
baby, of providing the natural food from her own 
breast for her baby. He should also give explicit direc- 
tions to the nurse in regard to the care of the breasts 
and nipples so that the latter may not get sore, a con- 
dition which not infrequently is accompanied by serious 
diminution of the flow of milk. 

The young, inexperienced mother needs to be 
instructed, according to Abt (Detroit Med. Jour., Feb- 
ruary, 1915), in the most elementary details concern- 
ing nursing. She is shown how to retract the paren- 
chyma of the breast from the nipple so that the infant's 
nose will not be buried in the mamma and respiration 



554 BREAST FEEDING 

will not be constricted in this manner. If she trains 
the baby to grasp the areola as well as the nipple, the 
milk flows more freely and the nipple is less liable to 
be traumatized and rendered painful. The nipples 
should be kept scrupulously clean, and may be washed 
before nursing, using plain water. Other solutions as 
well have been advised, among them weak solutions of 
boric acid. 

Craige (Jour. A. M. A., Feb. 6, 1915, p. 502) has 
summarized a number of practical instructions regard- 
ing the nursing infant. The proper interval for feed- 
ing should never be under two hours. Carlson and 
others have shown that the onset of hunger in infants 
occurs in from two and one-half to three hours. The 
three-hour interval is apparently that approved by most 
authorities although a few good pediatricians insist 
that four-hour intervals are correct. A night feeding 
between 10 p. m. and 6 a. m. is ordinarily unnecessary. 

The nursing mother should have exercise, plenty of 
rest, and be free of nervousness and worry. Too 
frequent feeding of the infant will result in continual 
dilatation of its stomach and in the production of 
dyspepsia. The proper correction of this dyspepsia 
lies with the mother. If necessary she may be given a 
tonic and constipation should be corrected with cas- 
cara or some mild laxative. 

In the composition of the milk, the fats and proteins 
are the constituents apt to be at fault. In cases in 
which fat is too small in quantity, the mother should 
take cow's milk, cereals, red meat, and plenty of exer- 
cise, fresh air and sleep. Nursing should be less fre- 
quent when the fat percentage is too great. In such 
cases the child may have colic after feeding, it may 
have facial eczema, or seborrhea of the scalp ; it 
vomits sour mucus, the stools smell sour and irritate 
the skin, and on staining with Sudan III particles of 
fat are visible in large quantity. The reduction of fat 
excess is difficult. The infant should, as has been 
stated, be fed less frequently. The diet of the mother 
should be modified to limit fat producing substances, 
the chief of which are the fats themselves. It may 
be necessary to feed only that portion of the breast 
milk containing small quantities of fat. The breast 



COLIC IN INFANTS 555 

pump may be used thus to eliminate the first or last 
part of the feeding to obviate undesirable surplus of 
any constituent. 

If protein is the disturbing element, causing colic, 
constipation or diarrhea with mucus stools containing 
tough white curds, in shape of bean — or peanut-like 
masses, the mother is probably leading a sedentary 
life and eating much meat and eggs and highly sea- 
soned food with lack of fruit and vegetables. 

COLIC 

In the foregoing, according to Craige, are found 
the causes, and, in a large measure, the prevention of 
colic. An attack of colic is unmistakable : the child 
cries violently, the abdomen is hard and distended, the 
knees are drawn up, and the hands and feet, which are 
never still, are cold from the intense intestinal conges- 
tion. The trouble may be either in the stomach, com- 
ing on soon after nursing, or in the intestines an hour 
or two later. Most mothers know all the mechanical 
remedies, such as hot applications, enemas, turning 
the baby over on his stomach, or holding him against 
her shoulder. It is often necessary to stop feeding 
entirely for twenty-four hours. Frequently, diluting 
the milk by giving water, lime-water, or barley-water, 
before nursing helps. Nursing a few minutes and 
stopping a short while, or the use of the nipple shield 
may be beneficial. Good results have been secured by 
Craige with peptonizing powder dissolved in warm 
w r ater and given before each feeding. Carminatives, 
milk of magnesia, sodium bicarbonate, magnesium car- 
bonate and bismuth subnitrate may often be used to 
advantage. In chronic cases, pulverized rhubarb or 
tincture of nux vomica sometimes gives relief. Sugar 
should never be used in the prescription for colic 
Glycerin is a good substitute. In many cases the elimi- 
nation of tomatoes, sour fruits and early vegetables 
from the mother's diet will prevent it. Where the 
condition has been long standing, improvement should 
not be expected to take place at once, for time must 
be allowed, both for the repair of the damage to the 
digestive tract, and more especially to the nervous 
system. 



556 INFLUENCE OF POSTURE ON DIGESTION 
LACK OF MILK 

When milk is insufficient in quantity the breasts are 
flabby, the baby does not seem satisfied. "Instead of 
nursing fifteen or twenty minutes and falling asleep, 
some fret and whine and pull at the nipple often for 
half an hour, while others give up entirely for a few 
minutes and then try again. The weight remains sta- 
tionary or shows only a slight gain. There is no colic, 
no vomiting ; the stools are scant, often with an olive- 
green tinge, and contain no undigested food. How- 
ever, unsatisfactory weight may be the result of over- 
feeding as well as underfeeding. It should be remem- 
bered, too, that weight fluctuations are common in 
infants, just as in adults ; therefore, the food should 
not be changed until it has been found that for two 
or three weeks there has not been an average weekly 
gain of from at least 3 to 4 ounces. With an abun- 
dance of good nourishing food for mother, regular 
habits for mother and baby, and mixed feeding, if 
necessary, in underfed babies, we always expect fav- 
orable results." 

CONTRAINDICATIONS 

Contrary to general opinion, menstruation is not a 
cause for stopping of nursing. Tuberculosis and a new 
pregnancy should be taken as sufficient cause. If 
milk is insufficient, breast nursing should be alternated 
with the feeding of correct milk mixtures. 

INFLUENCE OF POSTURE ON DIGESTION 

Smith and LeWald (Amer. Jour. Dis. Child., 1915, 
April, ix, p. 261) have recently studied this important 
subject. It is their belief that air is swallowed with 
the food by many if not by all infants. The erect pos- 
ture favors eructation of this air ; the horizontal pre- 
vents it. The horizontal posture by preventing eruc- 
tation, is an important cause of vomiting, colic, indi- 
gestion and disturbed sleep. The following routine 
should be followed in feeding every infant : Before 
feeding the infant should be held upright to allow the 
escape of any gas present in the stomach. Immediately 
after feeding the infant should again be held up 
against the shoulder of the mother or nurse. He may 
be patted on the back or gentle pressure may be made 



SUPPLEMENTARY INFANT FOODS 557 

on the epigastrium to encourage eructation of the 
swallowed air. It may be necessary to interrupt the 
feeding one or more times to hold the child upright to 
eructate, in cases in which an excessive amount of 
air is swallowed. After the gas is eructated the child 
should be put down to sleep, preferably in the prone 
position and with the head of the bed raised. If rest- 
less he may be taken up after a short time to see if 
there is more air in the stomach. Habitual tongue- 
suckers need to be held up several times between feed- 
ings, as they constantly swallow air. Other suckling 
habits must be prevented by mechanical restraint. 
Feedings should be given at as long intervals as pos- 
sible, depending on the gastric capacity and the total 
daily requirements. A feeding should not be taken too 
slowly. From five to ten minutes are enough as a 
rule; fifteen minutes should be the maximum time at 
bottle or breast. The importance of posture and the 
wrong teaching given to physicians and nursfes in the 
past warrant the emphasis laid on so simple a matter. 

SUPPLEMENTARY FOODS 

The choice of supplementary foods is a difficult 
problem. Cow's milk should be the basis, but when 
it fails, even after diluting, boiling or peptonizing, one 
should persist until sure that no food will agree as long 
as the baby takes the breast. As a temporary expedi- 
ent, some of the ethical proprietary foods may be suc- 
cessful, especially when the fat content in mother's 
milk is high. Constipation is better controlled by 
mixed feeding than by any other means ; give a bottle 
of cow's milk with a high percentage of fat, or some 
laxative food, or frequently milk of magnesia in one 
artificial feeding daily. After seven months it is best 
to use mixed feeding in all cases, Craige believes, with 
the idea of gradually training the infant stomach for 
the new food that weaning time will add. A 3 p. m. 
bottle without the nursing should be given, and later 
an additional one at 10 a. m. Frequently at about 
6 months, the mother's milk begins to grow less, and 
the fat percentage high, and the baby shows signs of 
fat indigestion. Under such a condition a bottle of 
milk containing a low fat mixture should be given. 



558 COW'S MILK 

When from any cause the mother's health is impaired 
and the milk is consequently below the standard, the 
needs of the infant may be temporarily supplied by 
the addition of artificial foods, thus giving the mother 
time to recuperate. 

WEANING 

No age limit can be set for weaning. By one year 
a normal baby will wean himself, according to Craige, 
if gradually a bottle of milk mixture is substituted 
for breast feeding, and cereals, toast with butter, 
broth, beef juice and coddled egg are added, depending 
on the growth and development of the child. Should 
the weaning time fall during the summer months, 
however, it is best to continue the mixed feeding until 
cool weather. At 9 months the average infant weighs 
about 17 or 18 pounds. Few mothers have milk that 
will furnish sufficient nourishment for a child of this 
size. In the majority of instances, where mothers 
attempt to nurse their babies after 7 months, to the 
exclusion of other foods, they do so at the risk of 
grave malnutrition or rickets. 

WET NURSING 

If the mother cannot or will not nurse her own baby, 
the next best resource is a good wet-nurse. By this 
means the baby is supplied with human milk, and if 
the nurse is healthy, and was delivered at approxi- 
mately the same date as the child's own mother, the 
substitute will usually prove very satisfactory. But 
practically, this method of feeding a baby is applicable 
to only a very limited number of the babies who are 
denied nourishment at their own mother's breast. 

COW'S MILK 

When human milk is unobtainable, the best substi- 
tute, from a practical point of view, is cow's milk, 
because it can generally be obtained in abundance in 
a more or less fresh state. Its composition is well 
understood, also the respects in which it differs from 
human milk. Like everything else in common use, 
it varies greatly in quality, and some of these varia- 
tions are intimately associated with unhealth fulness. 
Years ago consumers were especially disturbed by the 



CLEAN MILK 559 

abnormal proportion of water which many specimens 
of milk contained, and which was alleged to have been 
introduced surreptitiously by the producer or the 
dealer. This adulteration has largely been prevented 
by state legislation and the activity of local health 
boards. 

With increasing knowledge of fermentation and 
putrefaction, and the relation of bacteria to these proc- 
cesses, it became evident that milk, although kept free 
from intentional dilution and contamination, readily 
underwent deleterious changes under the influence, both 
of its inherent tendencies and of extraneous contami- 
nating matters accidentally introduced into it. At 
present the most important cause of the deterioration 
of milk and the development of deleterious qualities 
in it appears to be the growth of bacteria. It seems 
to be practically impossible, even with the greatest 
care, to secure milk which is entirely free from bac- 
teria, even when it is first drawn from the cow. Pos- 
sible sources of contamination are dust and dirt in the 
air of the barn or dairy, and manure and other dirt 
loosely adherent to the hair of the cow, the hands and 
the clothing of the milker, and utensils used in the 
transportation of the milk. 

It would consequently appear that the work of 
extracting the milk from the cow should be conducted 
in the same way as an aseptic surgical operation. 

1. The barn, or whatever place is occupied when the 
cow is milked, should be constructed so that it can be 
readily and thoroughly cleaned, and it should be 
cleaned at short intervals. This will be accompanied 
by a diminution in the amount of dirt and dust and 
bacteria in the air, and so the amount of contamination 
is diminished. 

2. The milker, whether milkmaid or milkman, should 
wear clean clothing and have his hands cleaned by 
careful washing. 

3. The cow should be made clean by washing and 
regular brushing, so that no manure adheres to the 
hair to be shaken or brushed off into the milk. 

4. The utensils used in handling the milk, and espe- 
cially the milk-pails, should be thoroughly sterilized 
by careful washing with boiling water. 



560 STERILIZATION AND PASTEURIZATION 

By using effective caution in these four particulars 
the contamination of the milk may be greatly lessened. 
As precautions in these directions are imperfectly car- 
ried out, the number of bacteria increases and the con- 
ditions are more favorable for early deterioration of 
the milk. 

Practically, most milk which is furnished to the con- 
sumer contains an abundance of bacteria, and an 
important practical problem is how their injurious 
effects may be avoided. It has been found that the 
growth of bacteria is prevented by a low temperature. 
Therefore, it is apparent that all milk should be cooled 
to a temperature not above SO F. as soon after it is 
drawn from the cow as possible, and it should be kept 
at a temperature not above 50 F. until it is used. 

Through appointment of milk commissioners it is 
now possible to secure certified milk from certified 
cows. The number of bacteria and their virulence 
have been checked and such milk if fresh may be 
assumed to be safe. 

STERILIZATION AND PASTEURIZATION 

Not so very many yeafs ago the advice was given 
to obviate infected milk by "sterilizing" it by boiling. 
It was even advised to sterilize all the milk which was 
fed to infants. This was soon found to be objection- 
able (1) because it altered the taste and made the 
milk less palatable, and (2) because exposure to such 
a degree of temperature as was necessary to boil milk 
produced such chnages in it, including a destruction 
of the enzymes, that it was not a good food for infants. 

Next in order to avoid this interference with the 
digestibility of the milk, it was proposed to subject 
the milk to such a temperature, below the boiling-point, 
as would inhibit the growth of bacteria and would not 
make other objectionable changes in it. This tempera- 
ture was found to be about 140 F., and the process 
of heating the milk to this temperature was designated 
as "pasteurization." In recent years pasteurization 
has been extensively employed, especially in large 
cities, and unquestionably with a favorable influence 
on infant mortality. 

Two methods are in use, a "holding" and a "flash" 
method. In the latter the milk is brought to a high 



INFANTILE CONVULSIONS 561 

temperature and allowed to cool ; in the former, it is 
held from fifteen to thirty minutes at a temperature 
which kills all organisms and spores. There seems to 
be little doubt that the "holding" method is preferable. 
Infants that are fed on a strict milk diet, and that 
pasteurized, seem susceptible to such diseases of altered 
metabolism as scurvy, rickets and purpura. The addi- 
tion of orange juice to the diet will be of aid in 
obviating such disturbances. 

INFANTILE CONVULSIONS 
Convulsions in infants are not a disease entity, but 
the demand for prompt treatment in every case has 
caused them to be considered as a group rather than 
in direct relation to the underlying cause. Needless 
to state, the condition, usually means a hyperexcitabil- 
ity of the nervous system. This may be related to 
heredity, the parents being neurasthenic or neurotic; 
to lowered vitality; to errors in nutrition, most fre- 
quent in those artificially fed ; to chronic diseases such 
as rickets, syphilis, tuberculosis; or to some derange- 
ment of the glands of internal secretion. These rather 
general causes may be further exaggerated by the 
presence of such exciting conditions as acute pain due 
to local infection; continued irritation, due to 
elongated or impervious prepuce ; to this type also may 
be referred those cases undergoing dentition. Because 
of the incoordination of the nervous system infants 
seem especially predisposed to convulsions, but the 
fact that the convulsion may be a manifestation of any 
acute infectious disorder, perhaps involving the ner- 
vous system should not be overlooked. It is possible 
also that the convulsions may be the first indication 
that the child is epileptic. 

As to the relation of nutrition to convulsions, 
Grulee (Amer. Jour. Dis. Child., 1913, March, p. 205) 
has been able to show that some irritating substance 
present in the whey of cows' milk may produce con- 
vulsions, which disappear when the whey is eliminated 
from the diet. 

There exists also a nervous reaction in infants which 
has been characterized as the "spasmophilic diathesis." 
It is marked by heightened irritability as measured by 



562 TREATMENT OF INFANTILE CONVULSIONS 

electric reaction and by definite signs, (Chvostek-tap- 
ping the cheek causes twitching of the corner of the 
mouth) of increased nervous irritability. The move- 
ments here, rather than being only convulsive, may 
show the tremors known as tetany. 

TREATMENT 

It is important that the convulsions be stopped early. 
Sometimes the mere placing of the child in a warm 
bath is sedative. At the same time cold may be 
applied to the head. If the convulsions are severe they 
may be arrested immediately by the use of chloroform. 
But a very little is required to quiet the little patient 
and it should be administered with caution. Rectal 
injections of chloral are much used in a dosage of 3 
to 8 grains. After the convulsions have ceased 
bromids may be given over several days to act as a 
sedative to the nervous system. A good cathartic 
(castor oil) should be given and perhaps an enema. 
Steps should be taken to ascertain the cause of the 
condition, and if possible to correct it. If an elongated 
prepuce is noted circumcision may be necessary. 

If a child shows signs of tetany, and certainly if 
it shows rickets, calcium is indicated, as well as food 
that contains calcium. Calcium may be given as 
limewater, as calcium lactate or as calcium glycero- 
phosphate. Calcium lactate 0.05 gm. (about 1 grain) 
may be given three or four times in twenty-four hours ; 
or 0.10 gm. (about 2 grains) of calcium glycerophos- 
phate may be given in the same frequency. Calcium 
lactate should be dissolved, calcium glycerophosphate 
should be given as powder, and either may be admin- 
istered in milk. 

If any one of the many reflex causes of convulsions 
has been diagnosed, the treatment that must be insti- 
tuted is self-evident. 

If it is decided that the trouble is a beginning epi- 
lepsy, the treatment should be directed toward remov- 
ing any possible evident cause. If no tangible cause 
can be discovered, bromids should be given more or 
less continuously to prevent, if possible, the epileptic 
habit. 



CAUSES OF INCONTINENCE OF URINE 563 

INCONTINENCE OF URINE IN CHILDREN 

This troublesome condition occurs mostly at night, 
and occurs in both boys and girls. More or less 
involuntary evacuation of the bladder at night is not 
considered abnormal in a babe or a young child, but 
when a child is over 3 years of age it must be consid- 
ered more or less pathologic. Among the most fre- 
quent causes are worms, elongated or adherent pre- 
puce or adherent clitoris, and the general restlessness 
and poor sleep caused by adenoid tissue in the pharynx 
interfering with breathing; less frequent causes are 
bladder irritation caused by an actual inflammation 
in the bladder, or by calculi. Of course simple or 
specific urethritis, vaginitis or any foreign matter in 
the vagina, diabetes mellitus, and diabetes insipidus 
may be causes. If none of these is present, it must 
be assumed that there is a congenital weakness of the 
sphincter muscle of the bladder, or that the urine is 
irritable and that there is a congenital hypersensitive- 
ness of the bladder, so that the least distention causes 
its contraction. The normal desire to urinate probably 
comes as a rule from the posterior portion of the 
urethra slightly dilating and allowing urine to trickle 
into it. If this relaxation of the sphincter occurs 
abnormally, of course the reflex desire to urinate is 
abnormally frequent. 

If any of the foregoing reflex causes of nocturnal 
enuresis are present, proper treatment will stop the 
wetting of the bed. If none are present, recourse 
must be had to various treatments. Perhaps more 
valuable than medicinal treatment is a rearrangement 
of the general management of the child. The loosen- 
ing of an adherent prepuce or an adherent clitoris may 
alone immediately cure the patient of wetting the bed. 

The diet is important in the general management 
of such a child, and as soon as it is of such an age 
that milk is not necessary for its food it is better to 
restrict the amount of milk, as nearly two-thirds of 
milk must be passed out by the urine. Of course 
coffee and tea should be eliminated from the diet of 
all children, especially of children suffering from 
this condition. The nearer the diet is vegetarian and 



564 TREATMENT OF INCONTINENCE OF URINE 

cereal, the better for the patient, as vegetables keep 
more water in the intestines and pass more water out 
by the bowels and less by the urine than does a diet of 
more or less meat. All fluids should be restricted after 
3 or 4 p. m. and the child should be awakened to urin- 
ate when the parents go to bed. Preventing the child 
from lying on its back and raising the foot of the bed 
are old methods which are pretty generally known. 
The object is to prevent, if possible, the urine trickling 
into the back part of the urethra and starting the 
vesical spasm. 

While the child may be treated psychically, or men- 
tally impressed with different physical treatments, and 
perhaps in some way frightened into keeping up a 
nocturnal memory picture of the necessity of waking 
when the desire to urinate occurs, still, the patient 
should never be punished, as this is rarely of any 
value. 

Various electrical treatments have been tried, and 
probably none any more successfully than the faradic 
with an indifferent electrode over the spine and an 
active small electrode applied over the bladder, over 
the pubis and over the perineum, and the current made 
sufficiently strong to cause more or less contraction of 
the tissues. Theoretically this application of electri- 
city may cause contraction and stimulation of the 
sphincter of the bladder, but most likely the greatest 
amount of good is done by the psychic effect on the 
child. Sometimes the galvanic or constant current, 
with the large electrode on the spine being the anode 
and the more active smaller electrode being the cathode 
and the current allowed to make and break, is 
successful. 

Often the passing of sounds has seemed to be the 
cause of improvement. In other cases a cold perineal 
douche, or cold-water spongings applied to the peri- 
neum apparently cures the condition. 

Medication has not been very satisfactory. Prob- 
ably the most successful drug is atropin, either in the 
form of belladonna or atropin sulphate, and the 
amount given should be sufficient to cause some physi- 
ologic action. The dose to begin with would be 1/500 



TREATMENT OF INCONTINENCE OF URINE 565 

grain of atropin sulphate to a child 5 years old, admin- 
istered at bedtime. This dose should be increased 
until some physiologic activity is evident. Frequently 
ergot is a successful medication, especially when there 
is a tendency to polyuria or diabetes insipidus. The 
ability of ergot to stimulate smooth muscle fiber is well 
understood, and that it is more or less of a sedative to 
the central nervous system is believed by many clin- 
icians. The ergot is best administered as a thoroughly 
active fluidextract in doses of 10, 15, 20 or more 
drops, depending on the age of the child, and given 
directly after the evening meal. 

Though almost any treatment may at times be 
rapidly successful, it must not be forgotten that many 
of these cases of nocturnal enuresis end abruptly 
without any special treatment, and the most inveterate 
cases frequently have the trouble cease at puberty, 
owing probably to a better development of all the 
muscular tissues of the genito-urinary tract. 



PHYSICAL THERAPY 



THE LOCAL APPLICATION OF DRY HOT AIR 

The general practitioner will usually not be able to 
apply the major elements of physiologic therapy to 
any great extent because of the elaborateness of the 
plant required, but some of the minor elements can be 
perfectly utilized by the general practitioner, and most 
gratifying therapeutic results obtained. The local 
application of dry hot air is one of the most useful of 
them. 

There are on the market several forms of apparatus 
for its application, all of which will do good work. In 
order to be efficient an apparatus must be capable of 
producing 400 degrees Fahrenheit in fifteen minutes 
at the outside, and of maintaining this temperature 
indefinitely. In order to be useful to the general prac- 
titioner these machines must also be easily portable. 
They may be heated by gas, gasoline, alcohol, or elec- 
tricity, but one that is to be used in general practice 
should be supplied with a gasoline attachment, what- 
ever other heating agent is usually employed, as the 
gas-pressure in some houses is not sufficient to produce 
an adequate degree of heat, electricity is available in 
only a few houses, and alcohol is not generally satisfac- 
tory for several reasons. 

Preparation of the patient for the application is 
simple, consisting merely in covering the part of the 
body to be treated with three thicknesses of loose- 
meshed Turkish toweling, so as to secure intimate con- 
tact between wrapping and skin. If the perspiration 
which is induced as soon as the heat strikes the skin, 
is allowed to remain on the skin during treatment, it 
will soon boil under the influence of the intense heat 
and blister the patient. These wrappings absorb it as 
soon as it is formed, the heat immediately vaporizes 
it and it rapidly diffuses itself out of the wrapping. 

Directions for the general operation of the machines, 
are furnished by the manufacturers. Complete trea- 



ACTION OF HOT AIR 567 

tises on thermaerotherapy can be obtained by those 
who take more than a passing interest in it. 

The physiologic effect of the dry hot air application 
is produced in two ways : first, by thermic irritation of 
the numerous nerve-endings in the skin, and second, 
by the actual raising of the temperature of those por- 
tions of the body in immediate contact with the heat. 

Irritation of the nerve-endings of the skin results, by 
reflex action, in (1) marked dilatation of the capillary 
areas, hence greatly increased blood-supply; (2) enor- 
mously increased functionation of the sweat-glands, 
hence increased local elimination, and (3) acceleration 
of the cell nutrition and function through reflex stimu- 
lation of the spinal centers. The raising of the tem- 
perature, en masse, results in acceleration of the 
chemical reactions constituting the cell metabolism of 
the part. It will be observed that the combination of 
these influences result in increased physiologic resis- 
tance of the tissues affected and acceleration of the 
process of repair of damaged tissue elements. 

The sphere of action of this application, then, is in 
the treatment of pathologic conditions which are 
strictly local in character, and which can be happily 
influenced by increasing the local physiologic cell resis- 
tance and the local nutritional, absorptive, and elimi- 
native functions. Such conditions obtain in many dis- 
eases encountered by the general practitioner but it 
will suffice to mention three which illustrate the differ- 
ent types of cases in which the local dry hot air appli- 
cation is most useful. These three are (1) sprains, 
(2) most cases of true rheumatism in which but one 
or two joints are involved, and (3) local septic infec- 
tion of the extremities before the process has involved 
the lymphatics connecting the affected part with the 
trunk, and in which the general toxemia resulting from 
the local lesion is not profound enough to overwhelm 
the organism as a whole. 

SPRAINS 

In an uncomplicated sprain the lesion consists simply 
of a traumatic solution of the continuity of soft tis- 
sues about the affected joint, accompanied by severe 
pain probably due to congestive irritation of lacerated 
nerve fibers. The therapeutic indications are (1) to 



568 HOT AIR IN RHEUMATISM 

relieve pain, (2) so to influence the trophic functions 
as to secure the quickest possible repair, and (3) to 
promote absorption of the exudate. 

Increase in the physiologic resistance of cells is not 
called for in this condition, but acceleration of the 
nutritional, absorptive and eliminative processes are 
indicated; practically clinical experience demonstrates 
that the local dry hot air treatment is well qualified to 
satisfy the requirements. If a sprain is put under 
treatment by this agent within three or four hours after 
the injury has been sustained, the pain will be relieved 
within half an hour, and all traces of the trouble will 
usually have disappeared within forty-eight hours. If 
the case is three or four days old, however, and exu- 
date is present to any great extent, complete removal 
of disability may require from two to three weeks ; but 
the pain is usually susceptible of the same immediate 
relief as in early cases. 

The local dry hot air application also serves as a 
valuable diagnostic test in these cases, by informing 
us as to whether or not a fracture coexists. When a 
fracture complicates the case the treatment will usually 
relieve the pain somewhat ; less frequently it will not 
relieve it at all, and sometimes it makes it worse. Its 
power to effect practically complete relief of pain is 
so universally observed when the lesion is uncompli- 
cated, that failure to produce such relief is almost 
positive evidence that a fracture is present. 

RHEUMATISM 

In this affection we have an acute, infectious, inflam- 
matory process, probably specific in nature, character- 
ized by intense pain and more or less effusion, both 
probably due to local toxin irritation. The therapeutic 
indications, then, are to increase the physiologic resis- 
tance of the invaded regions and to accelerate elimina- 
tion from this region. A sufficient increase in the 
physiologic resistance of the threatened cells would 
stop the invasion and immediately decrease the num- 
ber of the invading organisms, which would immedi- 
ately lessen the virulence of the toxemia attributable 
to them ; accelerating elimination would still further 
lessen toxemia ; and dilating the capillary areas would 



HOT AIR IN LOCAL INFECTIONS 569 

relieve blood-vessel spasm and whatever stasis of 
blood-vessel contents might be dependent thereon. 

Clinically, dry hot air demonstrates its capacity for 
producing all these effects and some cases of rheuma- 
tism can be cured by it alone. The proportion of such 
cases, however, is not large enough to justify confining 
our therapeusis entirely to this agent, and salicylic 
acid, in some form and in adequate dosage, should 
always accompany the dry hot air treatment. When 
these two remedies are used in combination, however, 
there result (1) immediate relief from pain, however 
severe, (2) a shortening of the duration of the dis- 
ease to from five to ten days, (3) a lessening of the 
likelihood of cardiac involvement because the rapidity 
with which control over the condition is obtained 
diminishes the time period during which the infection 
threatens structures other than those originally affected. 
When this picture is compared with that resulting from 
ordinary antirheumatic therapeusis, the beneficent role 
which dry hot air plays in the management of this dis- 
ease becomes at once apparent. 

This happy picture, however, applies only to uncom- 
plicated cases in which but one or two joints are 
involved, cases in which the general toxemia is not 
severe enough to depress the general nervous system 
seriously. When the general toxemia is very severe, 
the development of a satisfactory recovery will neces- 
sitate invoking the powerful influence on general 
metabolism ^nd elimination of the general or body 
application. The local application will be just as effec- 
tive in relieving pain but the relief will not last as 
long and it will not be as complete. Neither does this 
picture apply to cases of arthritis deformans, neuritis, 
inflammatory joint or bone lesions, or malignant dis- 
ease, which are so often misdiagnosticated as rheuma- 
tism. 

LOCAL SEPTIC INFECTION 

This is another condition in which the physiologic 
influences of local thermaerotherapy are most appro- 
priate. The disease process is of distinctly local origin, 
it involves a lowered vitality, or lack of physiologic 
resistance on the part of the involved tissues, and in 



570 HOT AIR IN LOCAL INFECTIONS 

the majority of cases it occurs on one of the extremi- 
ties at a considerable distance from the trunk. 

The therapeutic indications are (1) to increase the 
physiologic resistance of the invaded structures, 
whereby the. pabulum of the micro-organisms is so 
modified as to inhibit their development, lessen the 
virulence of their toxic emanations, and finally to 
accomplish their destruction; and (2) to eliminate as 
rapidly as possible the toxic products already present 
in the affected parts. 

A comparison of the physiologic action of this thera- 
peutic agent with the pathology and therapeutic indica- 
tions present in this ailment, explains at a glance why 
dry hot air would be expected to inhibit harmful 
attributes, and the clinical findings again bear out most 
happily the theoretical deductions. If a case is put 
under treatment before suppuration has been estab- 
lished and before the infective process has invaded 
that portion of the limb (lymphatics or other struc- 
tures) immediately contiguous to the trunk, the patho- 
logic phenomena will usually be abruptly arrested and 
the inauguration of convalescence will coincide with 
the first treatment. If suppuration at the point of 
infection has been established, the destructive process 
will become sharply and quickly localized when, by 
a stroke of the knife, the pus can be evacuated and 
the case brought to a rapid and satisfactory termina- 
tion. If, however, the lymphatics at the junction of 
the affected part with the trunk are involved or if 
general toxemia is severe enough to seriously depress 
the central nervous system, the local application will 
have to be either superseded or accompanied by the 
general or body treatment. 

Among other conditions in which the local applica- 
tion of hot air is more or less useful are pneumonia, 
pleurisy, acute gout, synovitis, fibrous ankylosis, some 
cases of neuritis, varicose ulcers, and sluggish healing 
processes not due to malignant, tuberculous or syphi- 
litic infection. The physiologic action of hot air is 
definite and constant and hence constitutes a reliable 
guide as to what sort of pathology will yield to its 
influence. 



HYDROTHERAPY OF MENTAL DISEASE 571 

HYDROTHERAPY 

The role of baths and hot^and cold applications in 
the treatment of disease has frequently been mentioned 
in the preceding articles. 

Recently Jackson (Jour. A. M. A., 1915, May 15, 
p. 1050) has discussed the use of hydrotherapy in the 
treatment of mental diseases. 



MENTAL DISEASES 

"The forms of hydrotherapy available," he says, 
"are ordinary sponging (cold or tepid), hot packs, cold 
packs, enteroclysis, hypodermoclysis and the free use 
of water internally. Hot packs and cold packs are 
especially advantageous in those conditions in which 
the tubs, cabinets and sprays are contraindicated. They 
are exceedingly useful in the extramural treatment of 
the insane, and possess unusual advantages in the intra- 
mural treatment of the various psychoses. The free 
use of water by mouth is indicated in all forms of 
insanity. Enteroclyses as well as hypodermoclyses 
are especially advantageous in the treatment of all 
cases showing exhaustion, excitement or depression. 
Swimming pools are useful for exercise and diversion." 

Hydrotherapy is employed in excitement, depres- 
sion, for elimination, toxemias, when relaxation, men- 
tal diversion or exercise is desired. 

WATER BY MOUTH 

Water by mouth should be urged in definite quanti- 
ties fixed by the physician. It is an excellent diuretic. 
When urging water, under various conditions, the 
amount of urine passed in twenty-four hours and the 
specific gravity of the twenty-four hours' output 
should be known, as well as the less frequently omitted 
examination for albumin and sugar. If the urine were 
more frequently examined during simple acute proc- 
esses the profession would be surprised at the fre- 
quency with which disturbances of the kidney func- 
tions are found. All to frequently, when an insufficient 
amount of urine is passed, more or less irritant diu- 
retics are given when simply an increased amount of 
water is needed. 



572 CABINET AND CONTINUOUS BATHS 

A caution should be noted here, that with real neph- 
ritis, or with an insufficiency of the heart, or a failure 
of the circulation, or when there is edema, large 
amounts of water should not be drunk. On the other 
hand, in conditions in which water should be admin- 
istered both as a diuretic and to dilute all the excre- 
tions, it is not sufficient for the physician to direct a 
patient to "drink plenty of water," but he should 
specify the amount of water he wishes taken during 
the twenty-four hours. 

Especially is it necessary, during acute infective 
processes in children, to urge their drinking plenty of 
water, perhaps as lemonade, orangeade, or barley 
water; but water in some form should be freely given. 

CABINET BATHS 

Cabinet baths are used in various toxemias to 
encourage elimination through the skin. Where there 
is marked physical deterioration, advanced circulatory 
or cardiorenal disease, they should be given with 
caution. 

This treatment should be given by trained atten- 
dants who can interpret physical symptoms. Medical 
stimulants should be close at hand, an ice cap applied 
to the head, and water given freely during the time of 
sweating. Perspiration usually becomes profuse at the 
expiration of about ten minutes, and the patients 
should pass immediately into the shower for subse- 
quent sprays in order to avoid catching cold. Cabinets 
should be well protected, all heat pipes or frame work 
properly protected, and doors to the cabinets should 
be such that they can be opened quickly. The neck 
should be well covered, and a large towel should 
enclose the patient's lower body in order that the pro- 
cedure may be done as modestly as possible. 

CONTINUOUS BATHS 

The continuous bath is usually a warm bath, which 
does not drop below 88 or exceed 100 F. It can he 
used in cases of depression as well as marked excite- 
ment. Aside from the therapeutic effect it seems to 
have a moral influence over certain incorrigible 
patients. Incorrigibility itself is not an indication. 



HYDROTHERAPY IN UROLOGY 573 

The bath may be administered in several forms ; tubs 
may have separate regulators, but preferably, one cen- 
tral stand should be the control. Patients may be 
given the freedom of the bath or they may be 
restrained, depending on the nature of the case as well 
as the therapeutic result desired. A bath of short 
duration at frequent intervals has more advantages 
than a prolonged bath of days or weeks. 

The contraindications are, first, the tub baths should 
not be prescribed for cases with marked physical 
deterioration, wasting or advanced physical diseases or 
skin diseases ; second, cabinet sweats are contraindi- 
cated in cases in which there is marked excitement as 
well as marked physical disease. 

HYDROTHERAPY IN UROLOGY 

Martin (Jour, A. M. A., Jan. 9, 1915, p. 102) has 
discussed various hydrotherapeutic measures of value 
in urology. 

Frequent applications of short fomentations, either 
hot or cold, cold compresses, or hot or cold immer- 
sions, he finds constitute a valuable adjunct to any 
treatment in combating infections. Cases of acute- 
specific urethritis experience relief and more speedy 
cure by immersing the organ in alternate hot and cold 
water several times a day, as an adjunct to regular 
treatment. 

THE SITZ BATH 

A frequently prescribed hydriatic measure by urolo- 
gists is the sitz. The proper technic should be fol- 
lowed and it has a marked analgesic effect. Patients, 
when taking their own treatment, find the relief so 
gratifying that they may remain in it too long, result- 
in an atonic reaction that is more or less debilitating. 
When used for its analgesic properties for calculus 
colic, this relaxed effect is desirable, but not so in 
combating chronic congestions or infections. "The best 
effect is obtained from a short hot sitz, from 115 to 
120 F., for five to eight minutes, followed by a short 
cold dip or effusion, the reaction of which prolongs 
the primary tonic effect of the heat, by producing a 
tonic dilatation of the peripheral vessels, and a more 
active circulation. A hot sitz should always be fol- 



574 THE SITZ BATH 

lowed by a cold sitz when treating chronic infections. " 
In private homes, Martin suggests the effect can be 
obtained in a measure by gradually cooling the water 
or dashing cold on the parts from a bucket. In cases 
of chronic infections, the advantage of such a bath is 
augmented by preceding it with alternate hot and cold 
sprays and ascending perineal douches. 

Martin emphasizes the value of the prolonged cold 
sitz. He noted that gynecologists use it effectively in 
the palliative treatment of uterine fibroid, with chronic 
congestion accompanied by menorrhagia. "They have 
demonstrated," he says, "by experience that the reac- 
tion following cold sitz baths increases the circulation 
in the uterus, which aggravates the menorrhagia, but 
prolonged (from twenty to thirty minutes at 60 to 
70 F.), produces continued contraction of the pelvic 
and abdominal viscera, with a relief of congestion fol- 
lowing. The prolonged active stimulation of the vaso- 
motors exhausts them, thus losing their power to 
react, so that the primary effect of the cold is con- 
tinued after the bath. Much of the benefit derived 
by the patient from this measure is due to the contrac- 
tion and tone to relaxed intestinal viscera, which 
noticeably increases their activity and thus stimulates 
nutrition and intestinal elimination." This measure 
has proved valuable in the palliative treatment of pros- 
tatic hypertrophies with congestion, malignant growths 
with hemorrhages, atonic dilated bladders (especially 
following prostatectomies) and in sexual debility. 

Care should be exercised at the start. Weak and 
debilitated patients should not be given the prolonged 
cold bath until their ability to react is established. 
This is accomplished by gradually reducing the tem- 
perature and extending the time from day to day. 
Reaction can be facilitated by a simultaneous hot foot 
bath, and especially by vigorous friction to parts 
immersed. Chilling is prevented by protection of the 
shoulders with flannel. The cold sitz should be pre- 
ceded by a hot rectal irrigation, and followed by a 
spray. It is positively contraindicated in all cases of 
vesical tenesmus. 

The neutral sitz, taken with water at 92 to 95 F. 
for from fifteen to thirty minutes, Martin finds valu- 



GRUELS AND STARCHY DRINKS 575 

able, because of its soothing and sedative effect in all 
irritable conditions, accompanied by priapisms and 
erotomania. 

Another useful measure which can be utilized by 
patients at home, is the heating pelvic pack. A piece 
of linen, flannel and mackintosh, shaped and applied 
like an infant's napkin, is used as a heating compress 
to any other part by wringing the linen out of ice water, 
and applying next to the skin, covered by flannel and 
mackintosh. Its action produces dilatation of super- 
ficial vessels, with relief of internal congestions. It 
possesses a decided value in the relief of pain and for 
activating the circulation in cases of cystitis, prosta- 
titis, epididymitis, and similar complaints. It is a 
valuable after-treatment following a sitz or hot fomen- 
tation, and is best employed at night. 

General measures, such as packs and electric light 
baths, and tonic measures, as hot and cold applications 
to the spine, salt glows and general hot and cold 
sprays, are valuable in stimulating general vital tone. 
With their proper use, weak anemic and debilitated 
patients, who may be suffering from some condition 
demanding radical treatment, and unable to stand it, 
may often be built up. 

Combinations of these applications, graduated as the 
patient's ability to react indicates, are effective in 
many cases of acute and chronic infections. 

The routine use of the hip and leg pack followed 
by cold-mitten friction after surgical procedures is 
sometimes a valuable measure to abort shock and pul- 
monary congestions. These are conveniently given by 
the use of the electric thermaphore pack, which is 
placed on the bed and the current turned on before 
the patient returns from the operating room. The 
patient is thus put at once in a warm, pack, which is 
folded around the legs and hips and heated by the 
electric current for ten or twelve minutes. A cold- 
mitten rub completes the treatment. 

GRUELS AND STARCHY DRINKS 

The food value of a starchy drink during certain 
illnesses is considerable; also, many thin, cereal liquids 
are very soothing to patients with gastrointestinal dis- 



576 GRUELS AND STARCHY DRINKS 

turbances. With seriously ill patients a happy 
arrangement of a mixed diet of some milk, some beef 
juice, and some thin, digestible, well-cooked starch 
makes the most appropriate food. 

The following suggestions of the way such nutri- 
tious drinks should be prepared are from "Practical 
Dietetics/' by Alida F. Pattee. For convenience an 
approximate estimate of the calorific value has been 
added to each receipt. 

FLOUR GRUEL 

Milk 1 cup 

Flour y 2 tablespoonf ul 

Salt 1 speck 

Raisins 1 dozen 

"Scald the milk, mix the flour with a little cold milk 
and stir into the scalding milk. Cook in a double 
boiler for one-half hour or on back of stove in sauce- 
pan. Stone and quarter the raisins, then add water 
enough to cover; cook slowly until the water has all 
boiled away; add to gruel just before serving, or eat 
with the raisins as desired. If there is much diarrhea 
the raisins should be left out/' 

Calorific value approximately 150 cal. 

BARLEY GRUEL 

Barley flour 2 tablespoonf uls 

Milk, scalded 1 quart 

Salt. 

"Blend the barley flour with a little cold milk and 
stir into the scalding milk. Cook in a double boiler 
two hours, salt to taste, and add sugar if desired ; 
strain." 

Calorific value approximately 650 cal. 

BARLEY GRUEL WTTTT BROTH 

Beef broth. 2 cups 

Barley flour 2 tablespoonf uls 

Cold water 2 tablespoonf uls 

Salt 1 saltspoonful 

"Mix barley flour and salt with the cold water to 
form a smooth paste. Add gradually to the boiling 



GRUELS AXD STARCHY DRINKS 577 

stock and boil one-half hour. Strain and serve very 
hot." 

EGG AXD SHERRY GRUEL 

Egg 1 

Sherry 1 wineglassful 

Lemon juice 1 teaspoonful 

Sugar 1 tablespoonful 

Grated nutmeg. 

Smooth hot gruel 1 cup 

"Beat the tgg, add wine, lemon juice and nutmeg, 
and pour on the hot gruel." 

Calorific value approximately 250 cal. 

ARROWROOT GRUEL 

Arrowroot . 2 teaspoonfuls 

Cold water .2 tablespoonfuls 

Boiling water or milk 1 cup 

Sugar, lemon juice, wine or brandy as required. 

"Blend the arrowroot and cold water to a smooth 
paste, add boiling water or milk and cook in a double 
boiler for two hours. Add salt, strain, and serve hot." 

Both the barley and arrowroot may be administered 
in diarrhea. 

Calorific value approximately 150 cal. 

INDIAN MEAL GRUEL 

Indian meal 1 tablespoonful 

Flour y 2 tablespoonful 

Salt %f teaspoonful 

Cold water 2 tablespoonfuls 

Boiling water \ l / 2 cups 

Milk or cream. 

"Blend the meal, flour and salt with the cold water to 
make a smooth paste and stir into the boiling water. 
Boil on back of stove one and one-half hours, dilute 
with milk or cream, strain." 

Calorific value approximately 250 cal. 

RICE GRUEL 

Rice flour 1 tablespoonful 

Cold water 2 tablespoonfuls 

Boiling water 1 quart 

Salt. 

"Mix the rice flour with a little cold water to form a 
smooth paste, add the boiling water, and cook in a 



578 GRUELS AND STARCHY DRINKS 

double boiler, until transparent and thoroughly cooked. 
Add salt to taste, sweeten, and add milk if desired; 
strain." 

Calorific value approximately 40 cal. 

OATMEAL GRUEL 

Coarse meal % cup 

Salt y 2 teaspoonful 

Boiling water \y 2 cups 

Milk or cream. 

"Add oatmeal and salt to the boiling water, cook 
four or five hours in a double boiler, adding more 
water if necessary. Strain, and dilute with hot milk 
to make it of the right consistency. Re-heat and serve. 
Sugar and a little port wine may be added if desired." 

Calorific value approximately 150 cal. a cup. 

FARINA GRUEL 

Farina 1 tablespoonful 

Cold water 1 tablespoonful 

Boiling water 1 cup 

Scalded milk 1 cup 

Salt. 

"Mix the farina with the cold water, add to the boil- 
ing water and boil thirty minutes. Add the scalding 
milk, taste and season properly. A little sugar may 
be added if desired, or an egg may be beaten and the 
gruel added to it." 

Calorific value approximately 150 cal. 

BROWNED FLOUR GRUEL 

"Tie one-fourth pound of wheat flour into a thick 
cloth and boil it in a quart of water for three hours. 
Remove the cloth and expose the flour to the air, or 
heat it until it is hard. Grate from it when wanted a 
tablespoonful, put into half a pint of new milk, and stir 
over the fire until it comes to a boil, add a pinch of 
salt and a tablespoonful of cold water, and serve. This 
gruel is excellent for children with simple diarrhea." 

BARLEY WATER 

Pearl barley V/ 2 tablespoonf uls 

Cold water 1 quart 

Salt enough 



GRUELS AND STARCHY DRINKS 579 

"Wash the barley, add cold water, and let it soak 
several hours ; drain and add the fresh cold water, 
boiling gently over direct heat for two hours, down to 
one pint, adding water from time to time ; salt to taste, 
and strain through muslin. Cream or milk may be 
added, or lemon juice and sugar. " This makes a 
demulcent drink, slightly constipating. 

RICE WATER 

Rice 2 tablespoonf uls 

Cold water 1 pint 

Boiling water or hot milk enough 

Salt enough 

"The carefully washed and cleaned rice should be 
added to the cold water and cooked an hour, or until 
the rice is tender. Strain, and dilute with the boiling 
water or hot milk to the desired consistency, and season 
with salt." Sugar or cinnamon may be added if 
desired or advisable. 

OATMEAL WATER 

Oatmeal 1 tablespoonful 

Cold water 1 tablespoonful 

Salt a little 

Boiling water 1 quart 

"Mix the oatmeal and cold water, add the salt, and 
stir into the boiling water. Boil three hours, adding 
water as it boils away. Strain through a fine sieve or 
cheesecloth, season, and serve cold." 

TOAST WATER 

Stale bread, toasted 1 cup 

Boiling water 1 cup 

Salt enough 

"Dry in an oven until crisp and brown, thin, inch 
squares of the bread. Take a cupful of this toast 
broken into crumbs, add water, and let it stand one 
hour. Strain through cheesecloth, season, and serve 
hot or cold." If advisable, milk or cream and sugar 
may be added. 



580 GRUELS AND STARCHY DRINKS 

ALBUMINOUS DRINKS 

EGG BROTH 

Yolk of egg 1 

Sugar 1 tablespoonful 

Salt 1 speck 

Hot milk 1 cup 

"After beating the egg, add the sugar and salt, and 
then pour on the hot milk. If desired this may be 
flavored with brandy or wine. 

Calorific value approximately 230 cal. 

EGGNOG 

Egg 1 

Salt 1 speck 

Sugar 1 tablespoonful 

Milk 2 / 3 cup 

Sherry wine \y 2 tablespoonfuls, or 

Brandy 1 tablespoonful or less 

"The beaten egg, with the added sugar and salt, 
should be chilled and the milk chilled before the whole 
is mixed with the liquor. A little nutmeg may be 
added if desired." 

Calorific value approximately 220 cal. 

JUNKET EGGNOG 

Egg 1 

Milk 1 cup 

Sugar 1 tablespoonful 

Rum, brandy or wine 2 teaspoonfuls 

Hansen's junket tablet Y\ 

"Beat the white and yolk of the egg separately very 
light, then blend the two and add the sugar dissolved 
in the rum. Heat the milk lukewarm, stir into the egg 
mixture and add quickly the tablet which has been 
dissolved in cold water. Pour into small warm glasses 
and sprinkle grated nutmeg over the top. Stand in a 
warm room undisturbed until firm, and then put on ice 
to cool. This can be retained by the most delicate 
stomach. " 

Calorific value approximately 250 cal - 



GRUELS AND STARCHY DRINKS 581 

BEEF EGGNOG 

Egg 1 

Salt 1 speck 

Sugar 1 tablespoonful 

Hot beef broth J/£ cup 

Brandy 1 tablespoonful 

"Beat the egg slightly, add the salt and sugar, then 
gradually add the hot broth, then the brandy, and 
strain." The sugar and brandy may be omitted, if pre- 
ferred." 

Calorific value approximately 150 cal. 

EGG AND BRANDY 

Eggs 3 

Cold water 4 tablespoonfuls 

Nutmeg a little 

Brandy .4 tablespoonfuls 

Sugar enough 

"Beat the eggs, add the cold water and brandy, and 
sweeten to the taste. Administer a tablespoonful at 
a time." 

Calorific value approximately 300 cal. 

ALBUMINIZED MILK 

Milk 1 cup 

White of tgg 1 

Salt. 
Flavoring. 

"Place the milk and egg in a covered glass fruit jar, 
shake until thoroughly blended, salt and flavor as 
desired. Strain and serve immediately/' 

Calorific value approximately 150 cal. 

ALBUMINIZED WATER 

Water (cold water boiled, and then cooled) . . 1 cup 

White of tgg 1 

Lemon juice. 

Sugar to taste 

'Tut all the ingredients into a covered glass fruit 
jar and shake until thoroughly blended, then strain 
and serve immediately. " 

Calorific value approximately 75 cal. 



MISCELLANEOUS 



ANESTHESIA 

ESSENTIALS OF SAFE ANESTHESIA 

Before commencing the administration of the anes- 
thetic, the anesthetist should give careful attention (1) 
to the operating-room; (2) to the emergency table; 
(3) to the patient. 

The operating-room must be warm, and the operat- 
ing-table as comfortable as possible for the patient. 
There must be plenty of blankets. The legs and arms, 
a low pillow for the patient's head, and a pillow for 
the back, should all be arranged to be as comfortable 
and warm as possible without, of course, interfering 
with the exigencies of the particular operation. It is 
advisable to have a strong, well-working faradic bat- 
tery, an oxygen tank (it should be remembered that 
Professor Henderson thinks too much oxygen in ether 
shock is inadvisable, and even advises carbon dioxid 
gas), transfusion apparatus, and warm, aseptic physio- 
logic saline solution. 

The articles on the emergency table should comprise : 

1. Chloroform. 

2. Ether. 

3. Petrolatum. 

4. Boric acid eye-drops (1 per cent.). 

5. Tongue forceps. 

6. Long forceps for swabbing, and properly made 
gauze or cotton pledgets (no ravelings), or pieces of 
sponge. 

7. A mouth-gag, or cork, or a piece of rubber. 

8. A large needle threaded with strong silk. 

9. A pus basin. 

10. Towels. 

11. Two hypodermic syringes. 

12. Atropin sulphate tablets (each 1/200 of a grain). 
(The amount is small, but the dose may be repeated, 
if needed.) 



DUTIES OF THE ANESTHETIST 583 

13. Strychnin sulphate tablets (each 1/40 of a 
grain). The amount is small, but the dose may be 
repeated, if needed.) 

14. Ampoules of saturated solution of camphor in 
sterile olive oil. 

15. Ampoules of aseptic ergot. 

1.6. Epinephrin solution in aseptic ampoules, 
1 : 10,000. 
The Patient: 

1. A twenty-four hours' specimen of urine should, 
if possible, have been examined ; certainly a single 
specimen should have been examined. 

2. The condition of the heart and arteries should 
have been examined and the best anesthetic selected. 

3. The patient should have received no solid food 
for a number of hours before the operation. If the 
operation is done early in the morning, it is best, three 
hours before the operation, to give either a cup of hoi 
bouillon or a cup of black coffee. 

4. The bowels should have been properly moved, 
generally by the aid of some cathartic, and often an 
enema is advisable at least an hour before the opera- 
tion. 

5. The urine should have been passed immediately 
before the administration of ether is begun. 

6. False teeth should be removed. The nose, throat, 
mouth and teeth should be cleansed with an antiseptic 
wash. Hairpins should be removed, if the patient is a 
female, and the hair should be properly bound up 
under a cap ; it is better that this cap is not made air 
tight as the head is likely to become very moist with 
perspiration, if the cap is impervious. 

7. The face should be anointed with petrolatum as 
the vapor of ether is irritant to the skin. 

8. The rate of the pulse and the feel of the radial 
and temporal arteries should be noted before the anes- 
thetic is begun. 

DUTIES OF THE ANESTHETIST 

The anesthetist should be a physician who is espe- 
cially trained for this work. He should devote his 
entire attention to the anesthesia, and his attention 
should not be diverted from his own work to the 



584 DUTIES OF THE ANESTHETIST 

operation, or for any other purpose. He should make 
himself aware of the condition of the heart by holding 
the index-finger of one hand over the temporal artery 
where it passes over the zygomatic process in front of 
the ear. He can be aware of the condition of the 
respiration either by the rise and fall of the chest or 
by feeling the exhalation of the air through the mask. 

Next to the pulse and respiration, the pupil of the 
eye is the most important index to the condition of the 
patient. Sudden dilatation of the pupil, especially if 
accompanied by hiccough, are grave symptoms, and 
should indicate the immediate suspension of the anes- 
thesia and the withdrawal of the ether. 

In order to determine when anesthesia is complete 
many separate the eyelids and touch the conjunctiva 
with the tip of the finger. This is a dangerous prac- 
tice and should not be followed, as the eye may be 
injured or infected. 

A most useful test for determining complete anes- 
thesia is raising the arm. If this falls without any 
muscular contraction, the anesthesia is complete. This 
condition may be present shortly after the administra- 
tion of the ether is commenced, the so-called primary 
anesthesia, which may be followed by a brief return of 
muscular activity. The continued administration of 
the ether will soon produce complete anesthesia. If 
the operation is an abdominal one, a little ether poured 
on the abdomen will soon show, by reflex action from 
the cold, whether the patient is thoroughly anesthetized 
or not. Also, manipulations of any kind at the region 
to be operated on will often awaken an incompletely 
anesthetized patient when other signs have apparently 
pointed to complete anesthesia. 

The patient should be kept as lightly under the 
influence of the anesthetic as is possible. Very deep 
anesthesia should be avoided. The anesthesia should be 
as brief as possible, but this, of course, rests with the 
operator. As soon as an operation is completed, the 
ether should be withdrawn. Often this can be done 
before the final stitches are inserted and the dressing- 
applied. If the patient has not been too deeply anes- 
thetized, he should begin to regain consciousness 
shortly after the withdrawal of the ether. 



COMPLICATIONS OF ANESTHESIA 585 

NAUSEA AND VOMITING 

One of the most troublesome of the sequelae of the 
administration of ether is nausea and vomiting. The 
exact cause of this has not been determined definitely. 
Some have believed that it was due to the irritation of 
the mucous membrane of the stomach from the ether 
swallowed, but this is probably not so, at least in all 
cases. Various methods have been proposed to com- 
bat this disagreeable symptom. All are more or less 
successful. If morphin has been administered before 
the operation, nausea does not occur as soon as when 
it has not been administered. It is often advisable to 
give an injection of morphin and atropin directly after 
the patient comes out of the anesthesia, that he may 
not suffer pain and shock from such pain. Such an 
injection prevents the nausea, at least for a number of 
hours. Hot water, administered frequently in tea- 
spoonful doses, is often a successful, simple treatment. 
If mucus and gas are eructated, or actually vomited, 
large draughts of hot water should be taken, that the 
stomach may be thoroughly washed out by vomiting, 
or by the liquid passing the irritant onward into the 
bowel. Some surgeons believe in washing out the 
stomach. This is not often advisable, but is indicated 
if bile is regurgitated, or if blood is extravasated into 
the stomach. Oxygen inhalations have been suggested. 
Pure olive oil, in ounce doses, has also been found use- 
ful in this condition. Of course, the oil would soothe 
the stomach, and would be especially sedative, if there 
was an increased amount of hydrochloric acid present 
in the stomach. 

BLADDER AND KIDNEYS 

A not infrequent sequence of the administration of 
ether is an irritable bladder and more or less local 
congestion. This is shown by a slight albuminuria and 
by a diminished amount of urine. Such an irritation 
may be caused not only by the ether itself, but also by 
the profuse sweating and the small amount of fluid 
which has been ingested, causing the urine to become 
very concentrated and therefore irritant. To avoid 
such irritation, it is often good treatment, before 
operation, to inject a pint of hot water, with or with- 



586 SALINES IN ANESTHESIA 

out salt (a physiologic saline solution), into the blad- 
der. Such liquid is rapidly absorbed and dilutes the 
urine and all the secretions and increases the excretion 
of urine. Such frequent irritation of the kidneys makes 
it inadvisable, unless there is positive necessity to 
administer ether a second time to the same person 
within so short a period as a week. In fact, it has been 
shown that serious kidney congestion can occur follow- 
ing an ether or chloroform narcosis several weeks sub- 
sequent to the anesthesia. The fact that this tendency 
to irritate the kidneys makes ether an anesthetic gen- 
erally contraindicated when there is kidney distur- 
bance, especially if there is any acute inflammation 
present. 

To hasten the elimination of ether from the system, 
plenty of fresh air should be allowed in the room, pro- 
vided it is sufficiently warm. The patient, under any 
circumstances, must be surrounded with hot-water bot- 
tles and blankets so that he may not lose too much heat, 
or better, may even acquire heat, during the shocked 
condition subsequent to anesthesia, such a condition 
being generally present. Such care that the patient 
does not lose heat is an important preventive of sur- 
gical shock. 

SALINES 

If much blood has been lost and the patient is in a 
condition of collapse, besides administering physio- 
logic saline solution by the rectum, intravenous or 
subcutaneous transfusions of saline solutions are often 
advisable. Raising the foot of the bed should also not 
be forgotten in this condition. It may be here paren- 
thetically stated that when the Trendelenburg position 
has been long used in an operation the return of the 
patient to a level should be brought about gradually, 
lest anemia of the brain be caused. 

When a patient has lost a large amount of blood, or 
there is a condition of shock already present, or it is 
feared that the patient is not going to stand the opera- 
tion well and yet the operation must be done, the blood 
from one or both legs should be shut off by tourniquets. 
When the circulation entirely ceases in the extremity 
so treated, the blood there contained is, of course, free 
from the anesthetic, and may be turned in to the gen- 



LUNG COMPLICATIONS IN ANESTHESIA 587 

eral circulation at such time as the anesthetist or the 
operator decides. The patient will of course be revived 
by such blood. Perhaps the extremity and its blood 
should not be shut off from the general circulation 
more than half an hour lest some trophic or nerve 
changes occur. Danger from clotting and therefore 
from emboli might well be considered, if there are dis- 
eased arteries. High blood-pressure and cerebral con- 
gestions may contraindicate this procedure. 

LUNG COMPLICATIONS 

Another untoward effect is sometimes observed in 
the supervention of an attack of pneumonia. It has 
been proved that either ether, chloroform, or alcohol 
diminish the resistance of the cells to bacteria. Pneu- 
monia is more apt to supervene when the narcosis has 
been deep and protracted. Many believe that it is 
also encouraged by the inhalation of cold air with 
the ether, and it also undoubtedly happens that the 
development of pneumonia is promoted by the expo- 
sure of the patient, while under the influence of the 
anesthetic, by allowing the coverings to slip off from 
his body and limbs, or from allowing him to lie in 
coverings or clothing saturated with blood or other 
fluids used during the operation. It is exceedingly 
important that a patient under an anesthetic should 
be kept warm and dry. Various devices have been 
designed for keeping the patient warm by appliances 
connected with the operating table. These are often 
useful, but caution should be exercised lest the patient, 
while unconscious, should be burned by such appli- 
ances. 

As just stated, pulmonary congestion and post- 
operative pneumonia are frequent serious occurrences 
after prolonged anesthesia, especially after prolonged 
etherization. Various factors have been assigned an 
influence in the etiology of these pulmonary conditions. 
Among others, it has been alleged that probably the 
chilling of the respiratory organs by the evaporation 
of the anesthetic has an important part. It has been 
observed that anesthetics seemed to act better in warm 
climates and in warm weather. From these observa- 
tions it has been deduced that if the anesthetic is 



588 DISINFECTION 

warmed before it is administered, there will be less 
danger of pulmonary sequelae. During the last ten or 
fifteen years many anesthetists have insisted on having 
Lhe anesthetic itself, or the vapor, warmed before it is 
inhaled by the patient. This may be accomplished in 
various ways. For ordinary use, the warming of the 
can of ether or the bottle of chloroform to about the 
temperature of the body would seem to be most desir- 
able. The inhalation of an anesthetic at this tempera- 
ture results in less irritation in the throat at the begin- 
ning of anesthesia, the early accession of complete 
anesthesia, the necessity for a smaller amount of the 
anesthetic during the operation, and hence fewer after 
effects. 

Many patients complain of backache after an opera- 
tion. This is probably due in many cases to straining 
of the muscles of the back on account of the back not 
being properly supported while the patient is uncon- 
scious. In order to avoid this a small pillow should 
always be placed under the lumbar region of the patient 
while he is on the operating table. 

The question frequently arises whether to anesthe- 
tize the patient in the operating-room and on the oper- 
ating table, or in an adjoining room. With reference 
to this it should be urged that the less a patient is 
moved about after the administration of the anesthetic 
is commenced, the better. On the other hand, a nervous 
patient should generally be anesthetized in an* adjoin- 
ing room, and if possible, on a stretcher or rolling 
table, so that he may be transferred to the operating- 
room and then to the operating table with the least 
possible general disturbance. 

CONTRAINDICATIONS OF ETHER 

Ether is contraindicated if there is present disease 
either of the lungs or kidneys. Other contraindications 
to the use of ether are chronic alcoholism, aneurysm, 
very high blood-pressure, and an atheromatous condi- 
tion of the arteries. 

DISINFECTION 

The control of infectious diseases is inseparably 
connected with disinfection. The rational use of dis- 
infection began with the growth of our knowledge 



DISINFECTION DURING DISEASE 589 

of bacteriology. "To disinfect/' says Hasseltine 
(Pub. Health Reports, 1915, xxx, p. 2049), "is to free 
from infectious or contagious matter ; to make innocu- 
ous. To fumigate is to apply smoke, gas or vapor." 
He therefore considers as disinfecting measures those 
which attack the specific cause of disease, as fumi- 
gating measures those which by the use of smoke, gas 
or vapor, attack the specific cause indirectly, through 
the destruction of intermediate hosts, or carriers 
other than man, such as mosquitoes, rats, fleas, flies, 
etc. 

USE OF DISINFECTANTS DURING THE COURSE 
OF DISEASE 

If disinfection is properly carried out at the bed- 
side the need of much terminal disinfection is obviated. 
The secretions and excretions which the patient gives 
off are the source of infection through the virulent 
organisms contained in them. Although it is unneces- 
sary to disinfect all discharges in some diseases it is 
better to err on the safe side and to disinfect all of 
them. 

Sputum, nasal and other discharges should be 
received on cheap cloths and then incinerated. Solu- 
tions containing 5 per cent, phenol, 1 per cent, tricresol, 
compound cresol solution are also efficient. For feces 
and urine, about one gallon of boiling water may 
be added to a stool, which is then covered and allowed 
to stand until cool. Better still, however, is the follow- 
ing method devised by Prausnitz. A small amount of 
hot water is added to the stool, then fresh quicklime. 
The process of slaking raises the temperature and 
maintains it above the thermal death point of most 
organisms. 

Bath water is easily disinfected by the addition of 
crude carbolic acid. 

Soiled bedding and clothing are best disinfected by 
removal to a steam disinfecting chamber. Where 
this is unavailable, immersion in boiling water for five 
minutes, or in 5 per cent, carbolic acid solution for 
several hours is efficient. 

Mattresses may be disinfected only by steam under 
pressure. Otherwise they should be burned. 



590 LIQUID DISINFECTANTS 

Such articles as leather, morocco, or india rubber, 
furs, books and similar objects may be disinfected by 
long continued dry heat, 120 C. for an hour. Unless 
they are of considerable value, however, they are bet- 
ter burned. 

LIQUID DISINFECTANTS 

Mercuric Chlorid. — The solutions of mercuric 
chlorid are extremely poisonous. Recent epidemics of 
poisoning have made their use in the home undesir- 
able unless carefully guarded. Tablets are now pre- 
pared colored, threaded, in odd shapes and put up 
in various ingenious warning packages. In strength 
of 1 :1,000 it destroys practically all organisms ; 1 : 500 
kills spore-bearing bacteria. Solutions are corrosive 
to metal containers. The following mixture which 
contains mercuric chlorid in a strength of 1 : 1,000 is 
recommended by Parkes : 

Mercuric chlorid y 2 ounce 

Hydrochloric acid 1 ounce 

Anilin blue dye 1 grain 

Water 3 gallons 

Phenols. — This group, of which carbolic acid is the 
one most widely known, forms the basis of most com- 
mercial disinfectants. A 5 per cent, solution of car- 
bolic acid is usually employed. 

Copper Sulphate. — In 5 per cent, solution this salt 
acts as a strong disinfecting agent and through its 
power to absorb ammonia and hydrogen sulphid, it is 
a good deodorant. * 

Zinc Chlorid. — A 10 per cent, solution of zinc chlorid 
to which a little hydrochloric acid has been added is 
used for spore-forming bacteria. A 5 per cent, solu- 
tion suffices for other organisms. Its action in gen- 
eral resembles that of copper sulphate. 

Potassium Permanganate. — The solutions of potas- 
sium permanganate stain anything with which they 
come in contact. At least a 5 per cent, solution is 
required for killing most organisms. The drug is a 
rather expensive one. 

Chlorid of Lime. — This substance has been men- 
tioned for use in disinfecting stools. It is important 
that the large masses of the stool be broken up in 



TERMINAL DISINFECTION 591 

order that the lime have a chance to act on the organ- 
isms. Not less than a 1.5 per cent, solution of the 
powder (about 2% ounces to the gallon) should be 
employed. 

Formaldehyd. — This substance is used chiefly as 
liquor formaldehydi, about 40 per cent, strength. It 
is chiefly used for its power to produce a disinfect- 
ing gas. 

Chinos ol, N. N. R., is a normal oxyquinolin sul- 
phate. It is a powerful antiseptic, non-toxic, and 
somewhat stronger as an antiseptic than mercuric 
chlorid or phenol. It is antiseptic in solutions of 
1 : 10,000. It is a feeble germicide, weaker than either 
phenol or mercuric chlorid. It is also an efficient 
deodorant. 

Cresol and compound cresol solution are official in 
the U. S. Pharmacopeia. These preparations are 
cheaper than phenol. Their disadvantages are the dis- 
agreeable odor and their variable composition and 
activity. While less toxic, they are far from being 
non-poisonous. 

Trikresol, N. N. R., is a liquid consisting of three 
cresols. 

Phenoco, N. N. R., is a mixture of coal tar creosote 
and higher phenol-homologues in soap solution. It is 
stated to be non-caustic, non-irritant and for mam- 
mals, one-half as toxic as phenol. 

Kresamine, N. N. R., and Disinfectant Krelos, 
N. N. R., are cresol preparations. The former con- 
sists of a watery solution of 25 per cent, tricresol and 
25 per cent, ethylenediamine. It is claimed to be less 
irritating than other antiseptics and more penetrating 
to animal tissues. 

Terminal Disinfection. — With reference to the more 
common infectious diseases, such as diphtheria, scarlet 
fever and measles, some authorities believe that ter- 
minal disinfection is unnecessary. Their claim is 
based on the belief that conditions are unfavorable for 
the multiplication of organisms outside the body and 
that such organisms die shortly after their removal 
from animal tissue. The handbook of the Bureau of 
Infectious Diseases of the New York Department of 
Health says that "in diphtheria and measles, when 



592 TERMINAL DISINFECTION 

patient recovers the sick room is thoroughly cleaned 
and aired." 

Cleansing is a good method of terminal disinfec- 
tion. The floors and wood work, all mouldings, ledges 
and window casements should be scrubbed. A vacuum 
cleaner may be applied to the walls and ceiling, if such 
an apparatus is available. After cleaning, renovation, 
including painting, renewal of wall paper and calci- 
mining is a valuable measure. 

Wherever there is doubt as to the thoroughness 
w r ith which cleansing and renovation are accomplished, 
as well as bedside disinfection, and wherever possible 
without too great inconvenience, terminal fumigation 
should be done. Hasseltine recommends in combating 
disease carried by animal hosts, fumigation with sul- 
phur dioxid. The best results, he suggests, are 
obtained by fumigating all rooms of the structure sim- 
ultaneously. Five pounds of sulphur per 1,000 cubic 
feet are sufficient, and should be placed in a thin layer 
so as to burn rapidly. If fumigating only to destroy 
vermin, moisture is not necessary. Exposure of four 
to twelve hours is desirable. 

In those diseases that are apparently non-insect borne 
and communicable, formaldehyd may be used. This 
should always be properly applied. It should be used 
at a temperature of 65 F. or higher, and with a rela- 
tive humidity of 65 per cent, at the beginning of the 
process. Humidity and the required temperature may 
be obtained by boiling water in the room. If possible, 
all the gas liberated should be confined to the room 
fumigated. The following method devised by Dixon 
is a good one for the liberation of formaldehyd gas. 

Briefly, the procedure is as follows : Ten ounces of 
liquor formaldehydi and 5 ounces of potassium per- 
manganate are sufficient for 1,000 cubic feet of space. 
A large receptacle should be used, to avoid spattering, 
and this should be placed on a noncombustible sur- 
face. If there be not sufficient moisture present there 
will be some danger of the dry gas igniting. Several 
receptacles in different parts of the room are more 
effective than one large container. The permanganate 
is placed in the container and the formaldehyd poured 
over it. The reaction is shown by ebullition of the 



ANAPHYLAXIS 593 

fluid, slight or marked according to its temperature. 
When once started it continues until all available for- 
maldehyd has been liberated. 

In New York City, this method is modified by using 
75 gms. of permanganate in 90 c.c. of water, hot if 
possible ; then 30 gms. of paraformaldehyd are added. 
This is sufficient for 1,000 cubic feet. This method 
makes less weight to carry, as the water is obtained at 
the place where disinfection is to be done. The para- 
formaldehyd is more stable than formaldehyd solu- 
tion, the latter seldom containing the required 40 per 
cent. 

Dixon has recently reported favorable results by 
substituting sodium dichromate and sulphuric acid for 
potassium permanganate. The acid and formaldehyd 
solution are mixed and allowed to cool. This solution 
is then poured over the crystals of sodium dichromate, 
spread in a thin layer in a large container. The mix- 
ture is : 

Sodium dichromate oz. . 10 

Saturated solution formaldehyde gas.. pint.. 1 
Sulphuric acid, commercial oz.. 1.5 

ANAPHYLAXIS— ALLERGY 
PROTEIN POISONING 

The fact that bacteria could cause protein poisoning 
was first noted and the condition described, in 1903, by 
Victor C. Vaughan of Ann Arbor. Protein poisoning 
is the cause of most urticarial conditions, of many of 
the skin eruptions, of many of the simple, so-called 
febricula (a name applied to a fever lasting one or two 
days with no positive diagnosis determinable), and all 
of these disturbances are really forms of allergy. 

Some protein poisons may cause a lowered or sub- 
normal temperature rather than fever. This is appar- 
ently due to a marked dilatation of the peripheral 
blood-vessels, especially of the splanchnic area, similar 
to that in shock. With other protein poisonings there 
may be, for several days, an irregular temperature with 
morning remissions. If such poisonings persist and the 
toxins are not rapidly expelled, neutralized or 
destroyed, there will be an increased elimination of 
nitrogen and a progressive loss of weight. 



594 PROTEIN POISONING 

A scientific discussion of these protein poisonings 
has recently been presented by Vaughan (Jour. 
A. M. A., Nov. 15, 1913, p. 1761). 

The symptoms of many diseases are due to the 
so-called "parenteral" digestion of proteins. Hay-fever 
and paroxysms of asthma are caused in sensitive indi- 
viduals by the pollen of different plants, the emanations 
from different animals, or the dust or odors of many 
kinds of substances. Any susceptible individual may 
be sensitized, so to speak, by one or more of these irri- 
tant causes and not by others. The inhalation of some 
substances in almost intangible amounts may cause 
serious inflammation of the upper air-passages and 
even of the bronchial tubes. 

Many drugs taken internally may sensitize individ- 
uals who have peculiar idiosyncrasies against them, and 
may cause, primarily, gastric and duodenal irritation, 
and secondarily, disturbances similar to protein poison- 
ing (such as urticaria and swelling of the mucous mem- 
branes), which may become serious, as occasionlly 
seen with quinin, salicylates, antipyrin and other coal- 
tar products. Many of the so-called genito-urinary 
stimulants of the copaiba class may cause considerable 
irritation and eruption of the skin. 

Living bacterial cells, like other living cells, must 
form ferments to prepare their food for absorption. 
Consequently, as described by Vaughan, for a given 
bacteria to be poisonous to the human animal, for 
instance, it must have the ability to split up and feed 
on the proteins of the human being ; otherwise bacteria 
cannot grow and cannot harm the host. Another pre- 
requisite to such poisonings is that the ferments in man 
must not be immediately destructive to the invading 
bacterium, although ultimately antibodies may be 
formed in sufficient amounts to destroy it. A bac- 
terium, then, able to digest the proteins in man renders 
this host susceptible to its poisoning, unless he has 
been previously protected either by a previous infec- 
tion from the specific bacterium or by a previous inocu- 
lation or vaccination with the germ or its products 
which so promotes the formation of antibodies or anti- 
ferments that it renders the individual immune. This 



DEFINITION OF ANAPHYLAXIS 595 

is the scientific basis of vaccination and protective 
inoculation. 

The value of vaccine treatment is due to the fact 
that the general system is not producing ferments suffi- 
cient to eradicate the special bacterium and its poison, 
and the inoculation so stimulates the general produc- 
tion of antibodies or ferments, that the local disease is 
stopped and later eradicated. On the other hand, if a 
person is suffering from a general poisoning or infec- 
tion, such vaccines are of doubtful value or may be 
actually harmful by overstimulating the already worn- 
out antagonistic cells, and the individual is thus really 
injured by such vaccination. Therefore the frequent 
and careless use of vaccines is deplorable and often 
inexcusable. 

ANAPHYLAXIS ALLERGY 

If proteins are naturally digested in the stomach and 
intestines and are absorbed only as the molecular forms 
that normally reach the blood, no sensitizing or anaphy- 
laxis or intoxication will occur. If, however, the pro- 
teins are absorbed before they reach their final disinte- 
gration stages and are then digested parenterally, that 
is, outside of the intestine, or if they reach the blood 
through other channels or are injected directly into the 
tissues, such poisoning or "reaction" occurs, attended 
by more or less fever, nervous irritability, increase in 
the number of the white corpuscles, changes in the 
blood-plasma, kidney irritation, and frequently diar- 
rhea. The system, however, soon produces active or 
immune bodies to combat the specific ferment. 

DEFINITION 

By the word "anaphylaxis" is understood generally 
the more severe phenomena that appear when an ani- 
mal previously influenced ("sensitized") by a foreign 
protein, introduced into the blood and tissues by injec- 
tion or otherwise, after a suitable interval again 
receives the same protein into its blood and tissues as 
the result of injection or otherwise. Anaphylactic 
shock in the guinea-pig is the classical example. As 
these phenomena are regarded currently as the result 
of an intoxication with the products of protein split- 
ting, anaphylaxis may be looked on as a protein intoxi- 



596 DEFINITION OF ANAPHYLAXIS 

cation occurring when a prepared animal receives the 
proper protein into its system. 

At first the word anaphylaxis was used to describq 
the condition in which severe, violent phenomena occur 
on reintroduction of toxic proteins (eel serum, actinea 
poison) in animals previously injected with these sub- 
stances for purposes of immunization. This was con- 
trary to expectation; the previous injections, it had 
been assumed, would produce a condition of protec- 
tion, a prophylaxis ; as the directly opposite action 
resulted, the word anaphylaxis, meaning the reverse of 
prophylaxis, was coined to designate the condition. 
Before long, hypersusceptibility was introduced as 
synonymous with anaphylaxis. As a clearer insight 
into the nature of the condition was gained, especially 
through the work of von Pirquet on serum disease in 
man, it developed that in reality the reverse of pro- 
phylaxis or hypersusceptibility to poisonous substances 
is not concerned, but a change in the powers of the 
body to react on the introduction of foreign proteins. 
In order to indicate the nature of this conception, von 
Pirquet coined the word "allergy," which means altered 
reactivity. At present there seems to be general agree- 
ment that phenomena as different as the experimental 
anaphylactic shock in guinea-pigs, the various mani- 
festations, mild and severe, of serum disease in man, 
various "food idiosyncrasies, " such as egg asthma, 
poisoning by cow's milk, etc., and the tuberculin and 
similar reactions are all due to an altered reactivity of 
the body, altered by previous influence of the foreign 
proteins concerned on the antibody-producing tissues 
so that when the conditions are right the foreign pro- 
teins are broken up in such a way as to produce 
poisonous effects that manifest themselves in different 
ways, depending on quantitative and other relations. 
Hence the word "allergy" would appear to be an excel- 
lent word for the condition because there is in reality 
no increased susceptibility to any particular poisons, 
nor is it true that the reverse of prophylaxis exists, 
because the allergic (anaphylactic) phenomena are the 
result of reactions between antibody and antigen, inci- 
dents in the course of immunization. Accordingly, 
anaphylaxis, hypersusceptibility and allergy are being 



MANIFESTATIONS OF ANAPHYLAXIS 597 

used more and more as synonymous terms, anaphylaxis 
being applied perhaps more to the severer general 
symptoms, of which anaphylactic shock is the classical 
example, and allergy to the milder phenomena illus- 
trated by ordinary serum disease, tuberculin reactions, 
gonococcal reactions, etc. From what has been said, 
it may be noted that anaphylaxis, although applied to 
the same sort of phenomena as when introduced by 
Richet, no longer has the interpretative significance of 
its derivation and first usage. 

MANIFESTATIONS 

The length of time before the occurrence of hyper- 
sensitiveness or sensitization varies ; the poisoning may 
be acute, as in so-called "ptomaine poisoning" or in 
that which occurs from some such toxin as is found in 
toadstools ; or it may require a number of days for the 
person affected to be sensitized. Sensitization from a 
serum injection or from the absorption of some pro- 
tein irritant may not happen until after a series of 
days, perhaps a week, and this sensitization will often 
not be recognized until a second injection (the intoxi- 
cating dose) of the same serum is administered, or 
until more of the same protein poison is absorbed, 
when reaction becomes evident and is sometimes seri- 
ous in its outcome. Therefore, it cannot be too care- 
fully noted that injection of prophylactic or antitoxic 
serums should ordinarily not be repeated too long after 
the first injection has been given. This is not always 
true of all antitoxins or all bacterins, but it is more 
or less constantly in evidence. Sometimes the system 
becomes tolerant to this irritant, and a larger dose, 
given to obtain a desired reaction, will be borne. In 
other instances the patient becomes hypersensitive, and 
the repetition of a previously harmless dose mav cause 
an intense reaction. This has occurred with diph- 
theria antitoxin a number of times, and would occur 
with any horse-serum in patients who are susceptible 
to, and are always hypersensitized by, emanations or 
dust from horses. 

Persons peculiarly susceptible to horse-scrum may 
develop bronchial edema and severe symptoms within 
a few minutes or hours after an injection of diph- 



598 MANIFESTATIONS OF ANAPHYLAXIS 

theria antitoxin ; or, in certain instances, they may not 
develop the asthma, urticaria, joint-pains and fever 
until after a series of days. Such late symptoms are 
not generally dangerous, although albumin may appear 
in the urine, but generally the kidneys rapidly recover 
and all the symptoms disappear. Other persons may 
have an intense local reaction to an injection of anti- 
toxin or vaccine out of all proportion to the injury 
caused and later may show some of the general symp- 
toms. Such cases are very troublesome and more or 
less serious, but rarely cause death. 

When antitoxin is indicated in diphtheria, or horse- 
serum in hemorrhage, one should be sure to inquire 
whether or not the patient is an asthmatic or a sufferer 
from hay-fever, and especially if horse emanations 
cause either of these conditions. A preliminary injec- 
tion of a small dose, perhaps just a few minims beneath 
the skin, will indicate whether there is a marked sus- 
ceptibility. This phase of the subject has been fully 
discussed under the subject of antitoxin in diphtheria. 

This reaction of the blood, that is, anaphylaxis, to 
different poisons, seems to be the cause not only of the 
symptoms which follow vaccination against small-pox, 
typhoid fever and other diseases or infections, but also 
of the symptoms of hay-fever induced by different 
pollens, varieties of dust or odors. It is the cause of 
asthma in many persons ; of the urticaria produced in 
susceptible individuals by shell-fish, buckwheat or 
strawberries, and of the symptoms of sensitization or 
anaphylaxis which sometimes occur even from such 
ordinary foods as veal, pork, eggs, some kinds of 
cheese and milk. 

It seems also, with our greater knowledge of this 
blood disturbance, that quite probably the skin erup- 
tions of the exanthems, of typhoid fever, and even of 
primary syphilis may be due to this hypersensitizing of 
the blood by the proteins of the specific bacteria. Our 
recognition of the anaphylactic temperature caused by 
serums and toxins suggests that the fever process of 
the various infections may also be due to the protein 
poisoning caused by the germ of infection. 

Discussion of the treatment of these specific infec- 
tions would lead us astray, but the symptoms attributed 



MANIFESTATIONS OF ANAPHYLAXIS 599 

to the poisoning protein in the blood are more or less 
the same, namely, fever, irritation of the central ner- 
vous system, cutaneous irritability and perhaps erup- 
tion, more or less muscle pains and concentration of 
the urine with kidney irritation, lumbar backache, and 
either constipation or a diarrhea that shows bowel irri- 
tation without complete evacuation. In some instances 
vomiting is present, especially in children, and head- 
ache is frequent or constant, dependent on whether the 
absorption of the poison is intermittent or continuous. 

Whatever the infection or irritant that causes these 
symptoms may be, the general treatment is the same, 
namely, whatever of the poison is still in the intestine 
should, if possible, be removed by a free, non-irritating 
catharsis by castor oil, calomel, or a saline, as advis- 
able. It is quite possible that more of certain kinds 
of intestinal poisons may be absorbed under the influ- 
ence of an oil than would be if a saline is adminis- 
tered. If it is a poison to which the patient is sus- 
ceptible, he certainly should receive no more of the 
irritating food. If the disturbance is due to the pro- 
teins of some specific germ, he should receive only 
such nutriment as is easily digested, and therefore less 
likely to furnish incompletely disintegrated protein 
products for absorption, thus to add more irritants 
to the already disturbed blood. Consequently, indi- 
vidual idiosyncrasies should be learned and the signs 
of indigestion noted; the foods that probably will 
digest most readily and are not too rich in proteins 
are the only ones that the patient should be allowed. 

The next object is to dilute the poison already in 
the blood by the administration of large amounts of 
water, perhaps medicated, acidulated, alkalized, car- 
bonated or plain, as seems indicated. The greater the 
amount of urine passed, and the freer the perspiration, 
the sooner, in all probability, will the toxins be elimi- 
nated, unless they are produced in overwhelming quan- 
tities. 

If there is an antitoxin for the condition, it should, 
of course, be administered. The skin should be fre- 
quently soothed with warm water (often best made 
alkaline with sodium bicarbonate) sponging and then 
perhaps powdered with a simple bland powder, such 



600 CALCIUM IN ANAPHYLAXIS 

as starch. An irritated, erupted skin should not be 
freely sponged with pure alcohol, which dries the skin 
and will cause more irritation. The more moisture 
there is in a skin with an urticarial or exanthematous 
eruption, the less is the irritation and itching. The 
temperature is also more rapidly reduced by evapora- 
tion. If the fever is excessively high and must be 
reduced, of course the usual hydrotherapeutic mea- 
sures should be inaugurated. 

CALCIUM 

The nutritional value of calcium and its necessary 
participation in many functions of the body is described 
under that head. The relationship of diminished cal- 
cium content of the blood to some angioneurotic ede- 
mas and to some of the urticaria-like localized swell- 
ings and edemas, has been lately shown by investi- 
gators. It seems to be a clinical fact in many cases 
that these exudates and symptoms of anaphylaxis are 
prevented, or are quickly improved, by the adminis- 
tration of calcium. Experimental evidence as to the 
value of calcium in preventing anaphylaxis is rather 
contradictory. 

DRUGS WHICH CAUSE ERUPTIONS 

Urticarias, erythemas and scarlatiniform eruptions 
may be caused by belladonna, salicylic acid and arsenic 
or any other salts or preparations, antitoxin, many of 
the volatile oils and drugs containing them (as copaiba, 
santal oil, turpentine), some of the synthetic com- 
pounds (as antipyrin, sulphonal, etc.), chloral, quinin 
and its salts, and opium and any of its alkaloids or 
preparations. These eruptions appear in some patients 
after a single therapeutic dose of any of these drugs ; 
in others only when the drug is pushed, or when it has 
been given for some time. The frequency of idiosyn- 
crasy against these drugs follows about the order in 
which they are named. Arsenic will rarely cause an 
eruption, unless it is pushed to full physiologic action. 
Some patients acquire a drug tolerance and no subse- 
quent eruptions occur after the first dose or two. This 
is typically true of some persons who are susceptible 
to quinin. 



DRUG ERUPTIONS 601 

Unless the drug is being pushed to full physiologic 
action with a definite object or a tolerance is expected 
and desired or the discomfort is unimportant, the 
drug should be stopped, a cathartic given, and sooth- 
ing, bland mucous membrane sedatives should be 
administered, such as bismuth subcarbonate, sodium 
bicarbonate, milk of magnesia or slippery elm or flax- 
seed infusions. Even milk and starch-water are some- 
times very efficient sedatives to the mucous membrane 
of the stomach and upper intestine if it has been irri- 
tated by a drug. Of course, it is possible that the drug 
has caused anaphylaxis and the irritant is already in 
the blood. Then the treatment consists of large 
amounts of water, a bland diet, alkalies such as potas- 
sium citrate, large doses of sodium bicarbonate, and 
perhaps calcium in some form. 

Bromids and iodids frequently cause skin eruptions, 
occasionally after the first dose, but generally after a 
series of doses. An eruption quite generally occurs if 
these drugs are at all continuously given. Some 
patients, like epileptics or syphilitics, who are given 
large doses of bromids and iodids for a long time, 
become tolerant and do not have the skin eruptions, 
unless the dosage is very large. The iodid eruption is 
likely to be papular, but is rarely pustular. The 
bromid eruption is papular and frequently pustular, 
and the bromids may cause serious skin eruptions. It 
is sometimes thought that when arsenic is given coin- 
cidentally with bromids this troublesome eruption is 
less likely to occur. It also should be remembered 
that if sodium chlorid is removed from or greatly 
reduced in the diet of the patient, such large amounts of 
bromids as were once given are unnecessary. There- 
fore, the eruption is less likely to occur. The iodids 
cause eruptions less often than the bromids. The 
eruption from either drug rarely causes itching, but 
it takes some time for the eruption to disappear, even 
when the drugs have been discontinued. 

The treatment of these eruptions is to stop the 
drugs, if possible, to cause thorough bowel elimina- 
tion, to give hot baths or body bakes or electric light 
baths, and massage, as all tend to promote a more 
healthy condition of the skin. In fact, the bromid 



602 FEBRICULA 

eruptions are less likely to occur if the skin is fre- 
quently cleansed and massaged during administration 
of large doses of the drug. 

FEBRICULA 

Some short-lived feverish conditions are still termed 
in medical books "febricula" ; still, such a term only 
means an undiagnosed condition. A slight fever last- 
ing but a day has been termed ephemeral ; lasting sev- 
eral days, a febricula. Probably the majority of the 
feverish attacks which occur more frequently in 
children are due to some protein poisoning combined 
with an intestinal upset, and the condition caused is 
an anphylaxis. They may be abortive attacks of an 
exanthem, or, in children, short attacks of glandular 
fever. They are not infrequently caused by a folli- 
culitis of the nasopharynx, which not being readily 
seen, is not diagnosed. Inflammation of the adenoid 
tissue in this region may also cause a febricula. Such 
patients generally recover rapidly under anv treatment, 
but, if possible, a diagnosis should be made and the 
proper treatment given. 

URTICARIA 

It is astonishing that most books on medicine give 
no description of this condition or of its treatment, 
though they mention it as a symptom in certain con- 
ditions, such as liver disturbance, etc. ; but its discus- 
sion should be no more limited to books on diseases of 
the skin than the eruption of measles should be. 
Urticaria is not a skin disease, although it may be 
aggravated by certain skin conditions and perhaps 
also developed by certain disturbances, either vaso- 
motor or of the nervous system. 

The name "giant urticaria," sometimes used as a 
synonym for angioneurotic edema, should be reserved 
for serious large and changeable localized swellings. 
An angioneurotic edema may occur frequently or be 
present every morning in a patient's hands for 
instance, but ordinarily carries with it no probability 
of danger. When it is distinctly localized and does 
not move from place to place, it may be due to a 
neurosis of the vasomotor system causing a local 



URTICARIA 603 

dilatation and exudate, with perhaps associated con- 
traction of other vessels. It is a chronic condition 
and requires long-continued neurotic and nutritional 
treatment of the patient, although some gastrointes- 
tinal disturbance may be present. Giant urticaria, on 
the other hand, is a serious, dangerous affection, espe- 
cially if it attacks the face and mouth, as when pres- 
ent, it is likely to do at any moment, and dangerous 
swelling in the throat and larynx may occur. This 
condition should be treated energetically, and the 
patient should be under close observation. 

The treatment of giant urticaria is catharsis with 
calomel and saline cathartics ; a milk diet, if milk 
agrees with the patient; or a plain water diet; or a 
cereal diet. Calcium should be given, and alkalies in 
large doses. Occasionally, large doses of quinin, such 
as 60 eg. r 10 grains) twice a day, or good-sized doses 
of antipyrin, as 1 gm. (15 grains) three times a day, 
have seemed almost specific. Atropin pushed to 
physiologic action is sometimes of value. The exact 
cause of this serious condition has not been deter- 
mined. Doubtless, however, it is anaphylactic and 
due to protein poisoning. 

The causes of simple urticaria are food (protein) 
poisoning, intestinal parasites, poisoning by certain 
drugs, disturbances of the liver or kidneys, gout, con- 
ditions associated with an increased amount of uric 
acid in the urine, constipation, an abnormally dry 
skin, and, in fact, anything that impedes normal elimi- 
nation. Circulatory disturbances, especially when 
combined with high blood-pressure or arteriosclerosis, 
may be factors in causing urticarial eruptions. 

Urticaria may occur, however, from almost any 
feverish condition or from any infection, and simply 
becomes, then, an added symptom. Most frequently 
urticaria is the most important symptom, and from 
its intense itching is the cause of the patient seeking 
medical advice. 

The treatment of simple urticaria has been sug- 
gested, namely, catharsis, a limited milk or cereal 
diet, large amounts of water, the administration of 
alkalies, such as potassium citrate in 2 gm. (30 grain) 
doses, given four or five times in twenty-four hours, 



604 TREATMENT OF URTICARIA 

or some other alkali, if preferred. Potassium citrate 
may be given as follows : 

gm. or c.c. 

I£ Potassii citratis 40 1 or Si 

Aquae gaultheriae 200 1 A3 v 

M. Sig. Two teaspoonfuls, in water, every four hours. 

If it is known that the stomach and intestines have 
been irritated, bismuth subcarbonate and sodium bicar- 
bonate should be administered, and, if the patient does 
not quickly recover, some form of calcium. 

The patient should be kept cool. Thin and non- 
irritating underwear should be used. If the patient is 
a child or one in whom the condition tends to recur, 
linen or silk underwear should be worn. Warm baths, 
the water made alkaline with sodium bicarbonate, are 
soothing to urticarial patients, and will relieve the itch- 
ing. The skin should not be rubbed, but should be 
mopped, lest the drying process cause irritation and 
more itching. The localized spots may be sprayed with 
alcohol, cologne, or even mild acid applications, such 
as vinegar. Phenol solutions have long been used to 
dull the irritability of the peripheral nerves; a 
2 per cent, solution, with or without glycerin often 
suffices, as : 

gm. or c.c. 

I£ Phenolis liquefacti 4 HI xlv 

Glycerini 25 or A3 v 

Aquae menthae piperitae 

q. s. ad 200 AS v 

M. Sig.: Use externally as a lotion. 

[The preceding should be well shaken and should 
be labeled as poison.] 

Sometimes such applications as "extract of witch- 
hazel" or a bland oil like almond oil will be soothing 
to the irritated skin. If the urticarial spots are not 
in large numbers, such applications as camphor or 
chloral, with or without menthol, are often valu- 
able, as : 



gm. or c.c 
R Camphorae 

Chlqrali hydrati aa 2 

Glycerini 25 

Alcoholis q. s. ad 100 



or 3 ss 
flSi 



A3 



IV 



M. Sig.: Use externally. [Shake, and label as poison.] 



TREATMENT OF URTICARIA 605 

Or: 

gm. or c.c. 

I£ Camphorae 

Chlorali hydrati aa 2 3 ss 

Mentholis 1 or gr. xx 

Glycerini 25 A3 i 

Alcoholis q. s. ad 100 A3 iv 

M. Sig. : Use externally. [Shake, and label as poison.] 

Various dusting powders are often of benefit, espe- 
cially in children suffering from this condition. The 
simplest is powdered starch or a talcum powder. 
Sometimes stearate of zinc, with or without menthol, 
is of value as tending to adhere to the region that is 
irritated. 

When urticaria continues or recurs, as it does occa- 
sionally in its milder forms, the whole physical condi- 
tion, diet and personal hygiene, of the patient must be 
very carefully investigated. Some wrong condition 
will be found and when it is corrected the disturbance 
will disappear. Especially must the intestinal diges- 
tion be studied and the urine tested for indican. If 
constipation or indigestion is sufficient to cause indican 
to appear in the urine, measures to prevent the absorp- 
tion of the irritants will generally cure the urticaria. 
Occasionally in young or older persons in whom a high 
tension or arteriosclerosis has begun or who have 
insufficient kidneys, conditions of the skin exist that 
cause temporary reddening, and perhaps itching, with 
the least irritation. 

The skin may be so hypersensitive as to allow of 
what is termed "dermographia." This condition is a 
pseudo-urticaria, and the treatments that tend to 
relieve urticaria will generally relieve this condition. 

When there are angioneurotic edemas, a diminution 
of the sodium chlorid in the food will often be a valu- 
able adjunct to the other treatment inaugurated. This 
is especially true if the kidneys are at all insufficient. 



USEFUL DRUGS 



CALCIUM 

This element, owing to recent investigations in physi- 
ology and pathology, has become of exceptional inter- 
est therapeutically. Its relationship to the solid tissues 
of the body has, of course, long been known, but its 
relationship to the functions of the body, especially 
to those of the nervous system, has only of late years 
been investigated or understood. The young child 
cannot properly grow and the bones do not normally 
develop if long deprived of calcium. An adult has 
various functional, and at times pathologic, distur- 
bances from such deprivation. Again, a person may 
not be deprived of calcium, but may have such chemi- 
cal disturbances that he loses calcium more rapidly 
than he can metabolize it, thus suffering actual depri- 
vation. Certain conditions are immediately improved 
and may be soon cured by the proper administration 
of calcium. 

We are more and more coming to understand that 
condition of the body which may be termed a hyper- 
acidity, or at least a lessened alkalinity, especially of 
the blood. So-called acidemia (perhaps a misnomer, as 
the blood never reaches the point of acidity before a 
patient dies) is now known to be the terminal condition 
of many diseases, and is not limited to diabetic coma. 
The final serious outcome in persistent vomiting, star- 
vation from any cause, gastric intolerance following 
surgical operations, the vomiting, diarrhea and maras- 
mus of infants, and perhaps the final disturbances of 
nephritis, is more or less due to general hyperacidity. 
Imperfect excretion of acid or acid salts by the kid- 
neys or bowels will probably sooner or later cause 
serious functional and perhaps organic disturbances, 
and certainly some degree of denutrition. With such 
diminished excretion of acids the alkalies of the body 
are more or less neutralized and lost to the tissues, 
even if not excessively eliminated. The immediate 
result of such a diminution of alkaline salts is serious 



CALCIUM 607 

disturbance of the nervous system. Many gastro- 
intestinal troubles in babies and children are due to 
an excess of acid and a diminution of alkalies. 

The symptoms of such systemic hyperacidity (what- 
ever the disease) are those of fever, that is, increased 
temperature and pulse-rate, restlessness, insomnia, 
gastro-intestinal disturbance, and often nausea and 
vomiting. Gastric tetany seems to be due to the dimin- 
ished alkalinity of the nerve-cells or nerve-tissue, and 
it has been pretty conclusively shown that ordinary 
tetany is due many times to parathyroid disturbance, 
which is really the result of a calcium insufficiency. 
The lack of calcium also seems to be in evidence in 
many instances of infantile convulsions, especially in 
spasmophilia and acute nervous irritability. It may be 
a cause of meningismus in typhoid fever or other 
serious infections, and, perhaps, is one of the causes 
of epilepsy, or of an epileptic convulsion. Even in 
puerperal eclampsia when the kidneys are not found 
seriously insufficient, a considerable diminution of the 
alkalies, especially of the calcium salts, may be a fac- 
tor in causing the convulsions. 

It need only be suggested that the withholding of 
starches and carbohydrates and the feeding of meats 
and such proteins as tend to hyperacidity will always 
increase the tendency to eclampsia, epilepsy, spasmo- 
philia and convulsions, to say nothing of such acid- 
producing food as a cause of increased bowel toxemia 
and more irritation of insufficient kidneys. 

Many of the glands which have an internal secretion 
— the thyroid, parathyroids, ovaries and testicles, pitui- 
tary and the thymus in infancy and childhood — seem 
to take part in normal lime metabolism. The thymus 
contains a large amount of nucleoprotein and phosphate 
radicals, and, it would seem, must have a great deal to 
do with the formation of calcium and phosphate salts 
for the normal growth of bone. When the child has 
reached the age of puberty, at which time the largest 
part of its bone growth has been completed, this gland 
atrophies, and probably the thyroid assumes, besides 
its own work, such necessary metabolic work as the 
thymus has been doing. 



608 CALCIUM 

The relationship of the pituitary to calcium metab- 
olism has not been determined, but its relationship to 
enormous bone growth, as in gigantism and acromegaly, 
has been proved, and this extra growth cannot occur 
without a disposition of an abnormal amount of cal- 
cium bone salts. 

In excessive activity of the thyroid gland and the 
disturbances so well recognized as Graves' disease, with 
its hypernervous excitability, there is always improve- 
ment if meats and other, acid-forming foods are 
removed from the dietary, and a quieting effect on the 
central nervous system and apparently a diminution in 
the activity of the thyroid gland is produced if calcium 
salts are given. Whether these salts simply soothe the 
central nervous system, or whether an excess of them 
quiets the activity of the thyroid gland, has not been 
determined. The action noted, however, is a clinical 
fact. 

Ovarian disturbances have seemed to cause derange- 
ment of calcium metabolism. In many instances osteo- 
malacia has been traced to some ovarian disturbance, 
perhaps a hypersecretion, as such conditions have fol- 
lowed too frequent pregnancies. In some cases the dis- 
ease has been cured by removal of one or both ovaries. 

The relationship of the testicles to calcium is not 
known, but analogy indicates that they probably take 
some part in the metabolism of this necessary element. 
In some animals, from which the testicles have been 
removed, there has been a retention of phosphates and 
of lime, and the likelihood of convulsions is less in cas- 
trated animals than in those uncastrated,, which is one 
more proof that an excess of calcium in the system 
seems to inhibit the convulsive irritability of the cen- 
tral nervous system. 

The deleterious effect of an excessive amount of 
magnesium and a deficient amount of calcium in plant 
life has long been known. In the presence of an excess 
of magnesium the growth of a plant is slow and imper- 
fect and the plant may die, while with a diminution of 
the magnesium and the addition of a suitable amount 
of calcium, the plant will grow normally and vigor- 
ouslv. 



PHARMACOLOGY OF CALCIUM 609 

It has long been inferred, and has not been experi- 
mentally denied, that an acid excess in the system tends 
to neuralgias, neuritis and neurasthenic conditions. 

In diabetes mellitus the alkalinity of the blood is 
known to be greatly diminished. One of the conse- 
quences, if the diminution is not sufficient to cause 
coma, is the production of boils and carbuncles. 

PHARMACOLOGY 

Lime salts not only form a large portion of the 
inorganic part of bones and teeth, but they also occur 
in small amounts (estimated by Schwarz and Bass 
[Am. Jour. Dis. of Child., 1912, hi, p. 15] as 0.01 per 
cent, of the total amount of the body). According to 
this estimate, a child weighing 10,000 gm. (about 22 
pounds) would have only 0.50 gm. (about 7y 2 grains) 
of calcium in its soft parts. It has been foynd that 
there is more calcium in the brain before than after 
birth, and that the amount diminishes as the child 
grows older. The calcium in the blood has been found 
highest in the child, and this also decreases slowly with 
age, being higher in breast-fed than in artificially fed 
children. Children seem to retain calcium longer than 
adults, and evidently store it. This also is more in 
evidence in breast-fed infants than in those who receive 
cow's milk. 

It has been stated that it may not be the absence of 
calcium, but the relationship between sodium and cal- 
cium salts that allows nervous irritability, as it seems 
to be a fact that a diminution of sodium salts and an 
increase of calcium diminishes nervous irritability. In 
several instances the calcium has been found dimin- 
ished in the brains of children who had died from 
tetany. 

Even the soluble salts, Cushny states, are absorbed 
with difficulty, and the calcium salts "precipitate col- 
loids such as proteins, in much more dilute solutions 
than the alkalies, and the precipitate is not redissolved 
by dilution with water." While the calcium salts retard 
the absorption of fluid from the intestines, they still 
do not cause catharsis as do the magnesium salts. In 
fact, lime salts are many times constipating. 

Like iron, a very small amount of calcium is absorbed 
in the alimentary canal, the larger portion, whether m 



610 PHARMACOLOGY OF CALCIUM 

the form of soluble or insoluble salts, passing off in the 
stools. Even a considerable portion of the calcium that 
is absorbed is excreted by the epithelium of the large 
intestine and also passes off by the bowels, only a small 
proportion, in normal conditions, passing off by the 
urine. L. B. Mendel has shown that the administration 
of calcium will increase the elimination of magnesium 
in the urine, and similarly, magnesium, when absorbed, 
leads to a larger excretion of calcium. The calcium so 
excreted occurs mostly as a phosphate. 

Jacoby and Eisner (Berl. Klin. Wchnschr., July 21, 
1913, p. 1339), in an article on the influence of cal- 
cium salts on the kidney, show that in experimental 
glycosuria in animals the feeding of calcium causes a 
diminution not only of the sugar output, but also of the 
nitrogen. In fact, according to Jacoby, all excretion 
from the kidneys, except water, was diminished by cal- 
cium feeding, and later the animals died. An increased 
amount of calcium in the food or administered as a 
drug will decrease the phosphates in the urine, and also 
its acidity. 

Eisner found in a number of instances that the feed- 
ing of calcium to patients who had nephritis caused 
serious retention of substances which should be ex- 
creted by the kidneys, that not only was the albumin 
reduced in amount, but also the total nitrogen. He 
therefore believes that calcium, in any amount, should 
not be given to nephritic patients. 

It has been many times stated that in tuberculosis or 
in the pretuberculous stage an increased amount of cal- 
cium is lost both in the urine and feces. In fact, a 
demineralization has been thought to be a forerunner 
of the development of tuberculosis. 

While lime is present in so many articles of food that 
lime starvation is not frequent, unless deliberately 
planned (it should be recognized that a meat and bread 
diet may cause lime starvation), still some chemical 
condition may prevent the lime of the food from metab- 
olizing to its proper usefulness in the body. This same 
chemical or biologic mistake occurs in chlorosis when a 
young girl receives food rich in iron and yet becomes 
anemic. Or, as previously suggested, some internal 
secretion may be so disturbed as to produce a waste of 



LIME IN TUBERCULOSIS 611 

calcium by causing an increased output of lime from 
the body. Any such deprivation is of course more 
serious in infants and young children than in later life. 

Though it has been shown that lime is not necessary 
to the formation of fibrin, the fibrin ferment will not 
be formed and coagulation of the blood will not occur, 
except when calcium salts are present. While lime is 
necessary for the normal coagulability of the blood and 
to lessen the tendency to hemorrhage, still the adminis- 
tration of lime salts by the mouth will not quickly 
hasten the normal clotting. Such metabolism is slow 
and cannot be rapidly pushed by giving large amounts 
of lime. Yon den Yelden (Therap. Monatsch., Octo- 
ber, 1913, p. 685), however, has recently shown that 
the administration of calcium lactate (from 4 to 6 gm., 
or from 1 to \y 2 drams a day) for five days or more 
will stop such bleeding as occurs in scorbutus. 

It has been shown that calcium will strengthen a 
weak heart muscle, and clinically many a weak heart 
may be made to improve by adding calcium to the 
medication, when such improvement has not occurred 
before. 

It has long been clinically noted that many children 
suffering from diarrheas are benefited by small doses 
of calcium, and it may be true that the acute irritability 
of the nervous system which we term chorea (whether 
this disease is or is not caused by an infection similar 
to acute rheumatism) may be due to an increased loss 
of calcium by the body. Certainly calcium seems to be 
of benefit in quieting the nervous system of these 
patients. An enlarged thyroid gland in young girls 
and women is often reduced to normal size by the 
administration of small doses of calcium. 

LIME IN TUBERCULOSIS 

Besides the physiologic determination that there 
is a loss of lime in tuberculous and pretuberculous 
patients, for perhaps more than fifty years it has been 
thought that the hypophosphites were of value in pul- 
monary tuberculosis ; that they not only increased the 
appetite and nutrition, but also aided specifically in the 
healing of the tuberculous lesions. Chemically, how- 
ever, it has been shown that the hypophosphites leave 



612 CALCIUM IN PREGNANCY 

the body almost unchanged and non-metabolized. It 
is supposed that it is the phosphorus element in the 
hypophosphite combination that is of special value, but 
if any one of these salts is of value it is the calcium 
hypophosphite, and the value of even this is doubtful, 
as the calcium is likely to be precipitated in the intes- 
tine as phosphate or carbonate and excreted in the 
feces (Jour. A. M. A., March 8, 1913, p. 747). 

Calcium phosphate is perhaps the most valuable bio- 
logic salt in cellular development, but unfortunately it 
is not a simple matter to supply a deficiency in this salt, 
as administration of calcium phosphate as such will 
generally not be effective. The calcium molecule in 
whatever form presented must be broken up and rebuilt 
in the blood and tissue. 

Forced feeding of tuberculous patients and the enor- 
mous amount of eggs and milk once given such patients 
are not now considered advisable by a large number of 
physicians who are specializing in the treatment of pul- 
monary tuberculosis. 

CALCIUM IN PREGNANCY 

Many investigations have shown that during preg- 
nancy and the puerperium there is a diminished amount 
of calcium in the blood. A large amount of calcium is 
needed during pregnancy for the growth of the fetus, 
and immediately after parturition the diminished 
amount of calcium in the blood is probably due to its 
being excreted in the milk. It has been suggested that 
this withdrawal of calcium may cause a fatty infiltra- 
tion, and later, fatty degeneration of the liver-cells, and 
therefore a disturbed function of the liver. If this be 
true, it would seemingly contra-indicate the adminis- 
tration of chloroform during labor if calcium were 
thought to be deficient, the tendency of chloroform to 
cause liver disturbances being now well recognized. 

If the calcium is much diminished in the blood, the 
parturient woman may have considerable uterine hem- 
orrhage. This might not be a disadvantage, if a defi- 
cient liver caused toxemias of the blood and a tendency 
to eclampsia. Free uterine hemorrhage is of advantage 
as a preventive of eclampsia during and after partu- 
rition. 



LIME IN RICKETS 613 

While some more recent investigations by Linzen- 
meier (Zentralbl. f. Gynak., June 28, 1913, p. 959) 
have shown that in the blood of some pregnant women, 
at least, there is an increased proportion of calcium, 
and that there may not be a decrease of calcium during 
eclampsia, the need of the body for an extra amount 
of calcium during pregnancy is unquestionable. The 
corollary to the proposition that a lime deficiency is 
likely to be always more or less in evidence during 
pregnancy, and that it is macroscopically shown by the 
decay of the teeth during this condition, is that preg- 
nant women should be given calcium salts medicinally 
and considerable amounts of foods rich in calcium. 

It is also quite possible that, if the mother has a 
deficient supply of lime, the fetus may start its life 
handicapped by a lime deficiency, its bones may not 
grow properly, its teeth may not erupt properly, and 
even later the teeth may decay quickly. Be this sup- 
position correct or incorrect, the mother should cer- 
tainly receive foods rich in calcium during pregnancy 
and during lactation. These foods are cheese, milk, 
yolk of egg, spinach, beans, peas and many fruits. 
Bread, the white of egg, rice and potatoes contain little 
calcium, and meat a very small amount. 

LIME IN RICKETS AND OSTEOMALACIA 

There is no question of the fact that lime is deficient 
in these diseases. It is only in rare instances, how- 
ever, that the patients are taking food that is seriously 
deficient in calcium; usually there is, instead, a faulty 
calcium metabolism. Therefore, the administration of 
calcium as a drug to these patients does not give satis- 
factory therapeutic results. It seems to be a fact that 
bottle-fed infants, even when given cow's milk, are 
more likely to suffer from rickets than is the breast-fed 
infant. It is quite probable that some internal secretion 
necessary for perfect nutrition is secreted in the 
mother's milk, may be absent in cow's milk, and hence 
bottle-fed children may not receive it. It is also quite 
probable that some children, even if breast-fed, suffer 
calcium malnutrition because of defective secreting 
glands in the mother. Also, one or more of the glands 
of internal secretion in such defective children may be 
acting insufficiently. 



614 LIME IN ARTERIOSCLEROSIS 

Many infants who do not develop rickets have dis- 
orders of digestion, and these are markedly benefited 
by the administration of calcium as a medicine. On 
the other hand, it can do no harm to administer calcium 
to rachitic patients. Small doses of pituitary extract 
may be of benefit in this disease. Thymus feeding has 
apparently failed to be of value. 

LIME IN SPASMOPHILIA, TETANY AND INFANTILE 
CONVULSIONS 

Disturbances of the parathyroid glands are more or 
less closely related to these conditions, and it has been 
found that the administration of calcium is as beneficial 
as is that of paratyphoid substance. Hence calcium is 
indicated as a part of the treatment in all of these 
conditions. Even gastric tetany has been benefited by 
the administration of the calcium salts. 

CALCIUM AND ARTERIOSCLEROSIS 

Recently, Scandola (Gaz. d. Osp., Sept. 7, 1913, p. 
1111) has stated his belief that in arteriosclerosis there 
is a retention of calcium in the tissues, on ordinary 
diets, and he believes that this retained calcium is 
likely to promote the progress of the disease and be an 
important factor in the disposition of calcium salts in 
the arterial system. He finds that nothing promotes 
the elimination of calcium more than the use of foods 
that contain little calcium, such as bread, potato, rice 
and meat. Cheese, milk, eggs and many fruits should 
be avoided. 

PREPARATIONS OF CALCIUM 

Calcii Chloridum, U. S. P. — This is a white salt, 
very deliquescent, soluble in water, an irritant, with a 
sharp, salty taste. It has many disadvantages and no 
special advantages over calcium lactate ; therefore, the 
lactate should be the salt most frequently used. The 
dose of calcium chlorid is given in the Pharmacopeia as 
0.50 gm. (7y 2 grains), but the dose of 0.30 gm. (5 
grains) is sufficient. It is generally administered three 
times a day, after meals, and may be given every three 
hours for several doses, if deemed advisable. As it 
is irritant, it should not be given on an empty stomach, 



PREPARATIONS OF CALCIUM 615 

but dissolved in some thick syrup and water, or in 
glycerin. 

gm. or c.c. 



gr. lxxx 

or AS iss 

flSiii 



1^ Calcii chloridi 6 

Glycerini 50 

Aqua menthae piperitae 

q. s. ad 100 

M. Sig. : A teaspoonful, in plenty of water, three times a 

day, after meals. 

Syrup of tolu may be substituted for the glycerin. 
Or syrupus calcis, U. S. P. (a syrupy preparation of 
calcium oxid may be administered in 2 c.c. (30 minim) 
doses. 

Liquor Calcis, U. S. P. — Lime water is a bland, 
non-irritant water solution of lime (calcium oxid), 
used internally as a mild antacid. Probably very little 
calcium, either in this preparation or in the syrup of 
lime, is absorbed, and the action of these preparations 
is largely on the bowels. They tend to cause constipa- 
tion, and are often of benefit (particularly the lime- 
water) in diarrheas, especially in infants. Lime-water 
is often added to milk, not only to increase the cal- 
cium content, but to prevent the acid of the stomach 
from causing rapid coagulation with the formation of 
large curds, since small curds are more easily digested. 
As lime-water is a harmless preparation, the amount 
added to an infant's milk should not be too small, and 
one, two or three teaspoonfuls may be added to each or 
to every other feeding, dependent on the age and the 
condition of the child. Externally, lime-water in equal 
combination with linseed oil forms linimentum calcis, 
U. S. P. (carron oil), a soothing alkaline protective, 
which has been used for many years as a sedative for 
the skin, especially in burns. 

Calcii Lactas, N. N. R. — Calcium lactate is a cal- 
cium salt of lactic acid. It is much less irritant than the 
chlorid, and is valuable when a calcium salt is indicated. 
It occurs as an odorless, tasteless powder, not very 
soluble in water, requiring twenty parts of cold water 
to dissolve it. The dose is about 0.30 gm. (5 grains). 
It is best administered in powder, taken weH diluted, 
or with milk or after meals. 

Calcii Glycerophosphas, N . N. R. — Calcium glycero- 
phosphate is the normal calcium salt of glycerophos- 



616 LECITHIN 

phoric acid. It is a fine white powder, without odor or 
taste, practically insoluble in water, and is best admin- 
istered in powder, tablet or capsule. The average dose 
is 0.30 gm, (5 grains) three times a day, after meals. 
This is probably the best salt of calcium to administer 
for nutritional results. 

Calcii Ichthyolis, N. N. R. — Calcium ichthyol is a 
derivative of ichthyol in which calcium is substituted 
for ammonium. 

Calcium Peroxide, N. N. R., and Calcium Phenol- 
snip honate, N. N. R., are used to obtain the action of 
the peroxide or phenolsulphonate respectively. 

Compound syrups of glycerophosphates, as calcii 
hypophosphis. U. S. P., and syrupns hypophosphitum 
composituSj U. S. P., are superfluous preparations. 

The precipitated calcium carbonate and prepared 
chalk may be used internally, but are most used exter- 
nally. They are mild alkalies, and tend to cause con- 
stipation. The official chalk mixture (mistura cretae, 
U. S. P.), is a harmless simple preparation. If it is 
desired to give a child chalk, however, it had better be 
given in powder form and added to whatever nutrient 
(as barley water, or milk) the child may be receiving. 
Chalk mixture must be well shaken, and the dose the 
child would receive is indefinite. 

The precipitated calcium phosphate is a preparation 
that has been greatly used and recommended in bone 
disturbances. It is an insoluble, white, tasteless and 
odorless powder. The Pharmacopeial dose is 1 gm. (15 
grains). Unfortunately, the calcium phosphate cannot 
be transferred as such from the intestine to bone struc- 
ture ; the calcium must be entirely metabolized in what- 
ever form it is offered, and therefore this powder in 
its large (bulky) doses is not needed. The glycero- 
phosphate is a better preparation. 

LECITHIN; EGG-YOLK 

Phosphorus is such a necessary element in the per- 
fect development and health of the cells of the body, 
and is so essential in the proper functioning of many 
parts of the body, especially nervous tissue, that any 
preparation said to present phosphorus in composition 
in assimilable form immediately causes clinical inter- 



PHOSPHORUS 617 

est. Lecithin is a compound of phosphorus that is 
found in the organism, hence, when it was artificially 
prepared for administration in various diseased condi- 
tions, it became very popular, and was and is highly 
lauded as a treatment for all kinds of debility, ane- 
mias, nervous disturbances, mental diseases and neu- 
rasthenia. 

In the first place, phosphorus is a constituent of 
nucleoproteins, and some kinds of phosphorized fats 
or lipoids, of which lecithin is an example. Phospho- 
proteins are contained in milk as caseinogen and in the 
yolk of egg as vitellin. 

The discussion ever persists as to which elemental 
form is of greater value for the nutrition of the body, 
an inorganic salt or an organic combination. This 
is particularly true of iron and of phosphorus. It has 
been demonstrated almost beyond controversy that an 
ordinary person can metabolize an inorganic iron as 
readily and as perfectly as an organic iron, and this 
seems to be more or less true of phosphorus, adminis- 
tered in the form of phosphates or other salts. Also, 
it has been shown many times that organic phosphorus, 
as presented in milk or in eggs, probably changes in 
the body to phosphates, and from these salts it is 
elaborated into products as lecithin, so that there seems 
to be no physiologic or biologic reason for preferring 
isolated lecithin as a medicament to such a phosphorus- 
bearing food as the yolk of egg. 

Phosphorus seems to stimulate metabolism, and often 
the person who receives phosphorus in any form seems 
not only to have an increased glandular and nervous 
activity, but also an increase in general nutrition. 
Phosphorus as an element, or such an active prepara- 
tion as zinc phosphid, should rarely be administered as 
a medicament, as either irritates the gastro-intestinal 
canal, overexcites the glandular system, especially the 
liver, and causes more or less irritation of the kidneys. 
When the question is one of nutrition and the stimula- 
tion of the metabolism of the body as a whole, and not 
of a treatment to ameliorate a troublesome symptom, 
or of an antidote to any diseased condition, it seems 
inexcusable to administer drugs that may do harm. 



618 PHOSPHORUS IN EGGS 

The lipoid lecithins are phosphatids, and are sub- 
stances of waxy consistence, soluble in alcohol, but 
insoluble in water. They are generally prepared from 
the yolk of eggs, probably are never quite pure, and 
contain about 4 per cent, of phosphorus. When leci- 
thin is broken up it results in glycerophosphoric acid, 
a fatty acid, and cholin, which is a more or less poison- 
ous nitrogenous base. 

Under the influence of lecithin the number of red 
corpuscles and the hemoglobin content in anemic con- 
ditions may be increased. That lecithin is a "brain 
food," or is a stimulant to cerebral activity has never 
been proved. All statements to that effect are falla- 
cious, in fact, there is no specific food for any part 
of the body. Certain nerve disturbances and certain 
cerebral and mental disturbances may at times increase 
the phosphorus output in the urine, and cause nucleo- 
protein, and, perhaps, lecithin disintegration ; but the 
mere administration of lecithin, as such could hardly 
be expected to improve such a condition. 

The logical measure, when a physiologic nutritional 
phosphorus is desired, is the administration of egg-yolk. 
The yolk of the hen's egg is stated by Friedenwald 
and Riirah {Diet in Health and Disease, 1913, p. 106) 
to represent 49.5 per cent, water, 15.7 per cent, protein 
and 33.3 per cent. fat. The yolk of the tgg is therefore 
rich in fat and protein, and has caloric as well as 
nitrogenous value. To obtain the activity of the leci- 
thin content in the yolk of the egg it is perhaps best 
to administer the yolk raw. It certainly seems to be 
a fact that the administration of one or two raw or 
even cooked yolks of eggs per day would give a patient 
all the lecithin that he could metabolize, and present it 
in a better manner than in an artificial preparation. 
In any condition of debility, anemia or nervous distur- 
bance the yolk of egg is as valuable as any or all arti- 
ficial lecithins, or any preparation that combines 
nucleins and nucleoproteins. 

It may be here stated, parenthetically, that the value 
of raw egg-white, or egg-albumin, as a nutrient has been 
very much overlauded, and dependence on egg-albumin 
as a food in serious conditions is a mistake. Egg- 
white has been found in some cases to pass very rap- 



ICTHYOL 619 

idly through the stomach without digestion, and to be 
incompletely digested in the intestine. Thus it may 
cause diarrhea, as well as fail to give nutrition. 

ICHTHYOL 

This is a non-official but much used preparation. It 
is a chemical combination of ammonium with a sul- 
phonic acid obtained by dry distillation from the bitu- 
minous shale found in the Tyrol. This shale contains 
the remains of fossil fishes. The chemical name is 
ammonium ichthyosulphonate or ammonium sulphoich- 
thyolate. It contains a great deal of sulphur, and the 
preparation was brought to the notice of the profes- 
sion by Unna, and was recommended for external use 
in skin diseases. It is applied to the skin in inflam- 
matory conditions such as erysipelas, acne vulgaris 
and rosacea, lupus erythematosus, etc., to lessen hyper- 
emia. It is a thick brown liquid which will mix with 
oils, fats, and with water. 

It is a mild antiseptic and resorbent and when mixed 
with glycerin or olive oil in from 10 to 50 per cent, it 
has been applied to boils, indurations, inflamed joints, 
and to chemically inflamed parts. If frequently painted 
over a part it may cause blistering, but once or twice 
painting the skin will cause mild counterirritation. It 
has been recommended lately as a local application to 
stop pain in neuralgia. Combined with glycerin (10 
per cent.) it makes a valuable vaginal tampon to reduce 
indurations and inflamations of the pelvis. It has 
been recommended for all kinds of skin diseases, both 
as an antiseptic and as a stimulant in chronic inflam- 
mations. In acute inflammatory conditions of the skin, 
as erysipelas and burns, weak solutions have been 
used with apparent advantage. 

Ichthyol has had considerable use internally in pul- 
monary tuberculosis. Its principal value in these 
instances is, probably, as an intestinal antiseptic. The 
appetite often increases and there is less intestinal 
fermentation, it acting in this manner much like creo- 
sote. The best method of administering it for this 
purpose is with an equal part of water, and, beginning 
with one drop of this solution three times a day, grad- 
ually increase it to ten or more drops. Pills or tablets 



620 BROMIDS 

of ichthyol may also be obtained. The same precau- 
tion in using excessive doses should be taken as in 
using large doses of creosote, viz., that it soon may 
over-stimulate the gastro-intestinal canal and a loss of 
appetite occur. It is also used internally for acne when 
this is due largely to intestinal fermentation. It may 
be ordered in pill form for this condition as follows : 

gm. or c.c. 
1^ Ammonii ichthyosulphonatis.. 

Pulveris glycyrrhizae aa 3| or gr. xlv 

M. et fac capsulas 20. 

Sig. : One capsule three times a day, after meals. 

A number of preparations occur in New and Non- 
official Remedies. 

HYPNOTICS 

It is impossible to enumerate the hypnotics in the 
order of their importance, as the importance of each 
individual drug varies with the condition to be com- 
bated : consequently the following are arranged alpha- 
betically. The official hypnotic drugs are : 

Bromids. Paraldehyd. 

Chloral. Sulphonethylmethanum 
Chloralamid. (trional). 

Hyoscin. Sulphonmethanum 
Morphin. (sulphonal). 

BROMIDS 

The bromids are used to produce sleep and to quiet 
the nervous system in conditions of irritability and 
excitation. Their action is largely as a sedative to the 
spinal cord, and also as a sedative to the cerebral cells. 
They are depressant to the circulation and, therefore, 
quiet circulatory excitement. Under their action the 
heart is slowed and the blood-presure falls ; conse- 
quently in any condition of serious heart or circulatory 
weakness bromids are contraindicated. On the other 
hand, in any condition of inflammatory irritations of 
the cerebrospinal system they are indicated. 

Their prolonged use tends to cerebral degeneration ; 
consequently in old age and in mental debility or melan- 
cholia, or with symptoms of paresis bromids should not 
be used. Their prolonged use also tends to produce 
muscular weakness as well as weakened circulation, 



INDICATIONS FOR BROMIDS 621 

sluggish digestion, loss of appetite, and, generally, 
imperfect nutrition. Mental actions become sluggish, 
the eyes lose their luster, the face becomes pale, and 
actual anemia may develop. The perspiration is 
increased and may be irritating and sour. The whole 
condition is that of great depression. Such a chronic 
condition caused by the administration of bromids has 
been termed "bromism," but the term should be con 
fined to the condition of chronic poisoning. 

As the bromids are partially excreted through the 
skin, they often, directly or indirectly, irritate it, and 
acne or various papular or even wartlike eruptions can 
occur. The more carefully the body is cleansed with 
baths during prolonged administration of bromids the 
less likely is the skin to show eruption. 

The over-action of a single dose of a bromid is shown 
by acute depression (lowered temperature, weak pulse, 
cold, clammy perspiration), impaired speech, tremor, 
profound sleep, perhaps stupor and, possibly, paralysis 
due to spinal depression. 

The treatment of such a condition would be the 
application of dry heat, atropin and strychnin hypoder- 
matically, black coffee by the mouth or rectum, and 
artificial respiration if it is needed. 

Acute poisoning by bromids is rare, as a single dose 
to produce poisoning is rarely taken. The large doses 
often administered in epilepsy do not cause poisoning, 
as the patient has become tolerant to such dosage. 

INDICATIONS 

Bromids are indicated as follows : 

1. To produce sleep. 

2. In hysterical conditions without neurasthenia. 

3. In acute cerebral excitement. 

4. In inflammation of the meninges. 

5. In convulsions caused by irritation of the brain 
or spinal cord (uremia, tetanus, hydrophobia). 

6. In epilepsy. 

7. As an antidote in strychnin or other convulsive 
poisoning. 

8. To prevent cinchonism. 

The only justification for administering bromids for 
a long period is in epilepsy, and in this disease it is 



622 INDICATIONS FOR BROMIDS 

a symptomatic treatment, though it seems at times 
to be curative. The size of the dose that should be 
used, the total amount and the length of time that the 
drug should be given must be decided by the symp- 
toms of the disease and by the action of the bromids 
on the individual patient. However, by greatly dimin- 
ishing the amount of sodium chlorid allowed in the 
food, it has been proved that therapeutic effects may 
be achieved from the bromids in epilepsy with much 
smaller doses than formerly were given. 

As above stated, the eruptions on the skin caused by 
the continued use of bromids can be much abated or 
even abolished by the plentiful drinking of water and 
by daily hot baths. The coincident administration of 
arsenic is also often successful in preventing these 
eruptions. 

There is no question that in hysterical conditions and 
conditions that simulate exophthalmic goiter (Graves' 
or thyroid disease) bromids given for some time are of 
great value. They are also valuable in the nervousness 
and vasomotor disturbances of the menopause. The 
value of a brimid is probably not only in its actual 
sedative action on the nerve centers, but also by its 
quieting action on the thyroid gland, which in all of 
these conditions shows more or less hyperactivity. 
While in hysterical conditions bromids, even when 
administered for several weeks, may do nothing but 
good, it constantly must be borne in mind that their 
tendency is to cause debility and malnutrition that it 
may be difficult later to combat. The dose of a bro- 
mid to meet these indications is not large, from 0.50 
gm. (7y 2 grains) to 1 gm. (15 grains), two or three 
times a day. 

As a hypnotic, the dose should be at least 2 gm. 
(30 grains), given from one to two hours before bed- 
time. More may be given if deemed advisable. A 
smaller dose is rarely of any utility. As a hypnotic, 
bromids should not be given for any great length of 
time. If a hypnotic must be given for any considerable 
time, some, substitute must be used, so that a habit 
for bromids may not be acquired. 

The bromids are valuable in preventing the unpleas- 
ant symptoms from large doses of quinin. The coin- 



BROMID PREPARATIONS 623 

cident administration of three grains of a bromid for 
every one grain of quinin, i. e., 1 gm. (15 grains) o'f 
a bromid to 0.30 gm. (5 grains) of quinin, will prevent 
cincjionism. Of course it would be inadvisable to give 
sufficient bromid to counteract the effect of the enor- 
mous doses of quinin given in pernicious malaria, but 
in ordinary intermittent fever during the period of the 
administration of fair doses of quinin to patients very 
susceptible to it, bromids are satisfactory. 

The drugs whose physiologic actions are more or less 
similar to bromids are those that are termed depresso- 
motors. They are chloral, physostigma (calabar bean), 
gelsemium and conium. Chloral, however, is the drug 
that acts most similarly to the bromids and may be 
substituted for them both as a hypnotic and as a 
cerebrospinal depressant. 

PREPARATIONS 

The following bromids appear in Useful Drugs : 
Potassii bromidum. Sodii bromidum. 

There is no reason for using lithium, calcium or 
zinc bromid. 

Strontium bromid is supposed to have a little less 
deleterious effect on the digestion than the other bro- 
mids have. The difference is so slight, however, that 
there is no good reason for using it. 

Ammonium bromid is more disagreeable than potas- 
sium or sodium bromid, and therefore is not often 
used. The pleasantest to take is the sodium salt. 

The sodium and potassium bromids are the ones most 
frequently used, and of these the potassium salt may 
be slightly more hypnotic, but if long given is more 
depressant to the circulation, as potassium is more of 
a heart muscle depressant than is sodium. Conse- 
quently, for prolonged use the sodium bromid is best. 

Hydrobromic acid should never be used as a substi- 
tute for bromid. While it causes bromid action, it is 
acid and therefore more irritant to the gastro-intestinal 
tract. There is no good reason for using hydrobromic 
acid. 

Numerous bromin derivatives are listed also in New 
and Nonofficial Remedies. 



624 CHLORAL 

The potassium and sodium bromids are best adminis- 
tered in plain water, though they may be given in effer- 
vescing water if preferred. Any syrup makes the salty 
taste of the sodium bromid or the flat taste of .the 
potassium bromid more disagreeable. 

Bromid tablets should never be swallowed whole, as 
these concentrated salts may seriously irritate the stom- 
ach and cause severe pain and even pseudo-angina pec- 
toris, and may even cause an ulcer of the stomach. 
Hence, whenever bromids are taken they should be 
ordered thoroughly dissolved and well diluted. 

gm. or c.c. 

I£ Sodii bromidi 20j or 3v 

Aquae 100| A3 iv 

M. Sig. : Two teaspoonfuls in water, two hours before bed- 
time. 

CHLORAL 

The action desired and expected from chloral is to 
produce sleep and to quiet excitability and irritability 
of the nervous system. 

Chloral hydrate is more or less irritant to the skin 
and mucous membranes, depending on its concentra- 
tion. If it is diluted or in syrupy solutions, which it 
forms when rubbed up with camphor in equal parts, 
while the first sensation may be that of burning, espe- 
cially when the skin is irritable, the secondary action 
is a sedative, the peripheral nerves being slightly dulled, 
and the part becomes mildly anesthetized. Chloral 
solutions or chloral combinations are therefore some- 
times used locally with good effect when there is burn- 
ing or itching of different parts of the body, such as in 
pruritus ani or pruritus vulvae. The same burning 
action occurs when it is applied to mucous membranes, 
and is followed by a dulling of sensation. If the 
solution is too concentrated it may cause ulceration; 
therefore chloral should never be administered in pow- 
der or capsule, but should always be given in solution, 
well diluted. 

Its primary systemic action is as a sedative to the 
brain and spinal cord. It seems to act specifically as a 
sedative to the brain cells and produces normal sleep. 
Whether this sleep occurs by actually stupefying the 
brain cells or by diminishing the circulation in thq 



CHLORAL 625 

brain has not been determined. It is the nearest to 
a perfect hypnotic that we have, and may be used 
whenever a soporific drug is needed, provided there is 
no serious cardiac or circulatory debility. After an ordi- 
nary sized dose the patient awakens in normal condi- 
tion, and without depression, unless the hypnotic has 
been frequently repeated. Larger doses will quiet the 
delirium of meningitis and will stop cerebral and 
spinal convulsions. When the convulsions are due to 
a spinal poison, as strychnin, or tetanus or hydro- 
phobia, the dose of chloral must be very large, almost 
poisonous. Consequently, when such an action of 
chloral is desired, it should be conjointly given with 
large doses of bromid, and if the convulsions are fre- 
quent and severe chloroform must be resorted to rather 
than the administration of dangerous doses of chloral. 

Chloral is a circulatory sedative, causing some vaso- 
dilatation, slowing, and in large doses weakening the 
heart. In diseased conditions of the heart it has been 
thought to have hastened death by causing cardiac 
failure. Except in small doses, it should not be given 
when the pulse tension is low and the heart action very 
weak. However, its quieting effect on the circulation 
and its causing, perhaps, much needed sleep has done 
a great deal more good than it has ever done harm. 
Small doses, as 0.20 gm. (3 grains) three times a day, 
have been given to reduce high tension in arteriosclero- 
sis. It will sometimes do this effectually in this small 
dose, but perhaps generally the nitrites or iodids act 
better. 

It circulates in the blood as chloral, and is excreted 
largely by the kidneys, ordinarily without causing irri- 
tation. It acts rapidly as a hypnotic, and should cause 
sleep in less than an hour. In concentrated solutions 
or when it finds the stomach in such a condition that 
it may be rapidly absorbed, or in a poisonous dose 
("knockout drops"), it can produce sleep very rapidly. 

In view of the fact that a few individuals show a 
peculiar idiosyncrasy for chloral — delirium, etc. — 
it is advisable to be cautious in giving it to a patient for 
the first time. 

The symptoms of its profound action are more or 
less profound stupor, dilated pupils, cold, clammy per- 



626 ADMINISTRATION OF CHLORAL 

spiration, weak heart action, feeble pulse, and gradu- 
ally failing respiration. 

The treatment of chloral poisoning or poisoning by 
"knockout drops" is to wash out the stomach with warm 
water or to remove its contents by emetics. The body 
temperature should be kept up with dry heat appli- 
cations, and strychnin should be given hypodermati- 
cally. If a full dose of strychnin, as 1/20 of a grain, 
does not improve the circulation, atropin in a dose of 
1/100 of a grain should be given hypodermatically. If 
the circulation still fails, resort should be had to intra- 
muscular injections of a saturated solution of cam- 
phor in olive oil, 1 c.c. (15 minims), which may be 
repeated every fifteen minutes for several times, if 
needed, or an epinephrin solution (1 : 1,000) given 
once, in a dose of 1 c.c. (15 minims). If the respira- 
tion fails, artificial respiration should be resorted to. 

If at any time after the administration of a thera- 
peutic dose of chloral cardiac depression occurs, strych- 
nin and digitalis should be given. 

ADMINISTRATION 

Chloral is a very disagreeable drug to take. It can 
not be given hypodermatically on account of the size 
of the dose and the irritation that it causes. It is 
rarely advisable to give it by the rectum unless convul- 
sions prevent its administration by the mouth. It has a 
nauseating, acrid, burning taste which is not readily 
disguised. It should always be given well diluted. 

Chlorahim Hydratum, U. S. P., occurs in crystals 
which are very soluble in water and alcohol. It is 
incompatible with alkalies. The ordinary dose is 1 gm. 
(15 grains), and when given by the rectum 1.50 gm. 
(22y 2 grains). 

As above stated, it is almost impossible to disguise 
the taste of chloral, but it is perhaps best administered 
in sour solutions, or it may be ordered in plain water 
and given in fresh lemonade. 

gm. or c.c. 

B- Chlorali hydrati 10| or 3 i ii 

Aquae 50 1 AS ii 

M. Sig. : A teaspoonful in half a glass of fresh lemonade, 
or in carbonated water, one-half hour before bedtime, 



ADMINISTRATION OF CHLORAL 627 

Or: 

gm. or c.c. 

R Chlorali hydrati.. 101 3 in 

Syrupi acidi citrici 25 1 or 

Aquam ad 50 1 AS i 

M. Sig. : A teaspoonful, in plenty of water, at bedtime. 

Or: 

gm. or c.c. 

B Chlorali hydrati 201 3 ivss 

Syrupi aurantii 50 1 or 

Aquam ad 100 1 fig iss 

M. Sig.: A teaspoonful, with plenty of water, as directed. 

Chloral is often combined with one or more bromids. 
Generally, however, it is best to have these nerve seda- 
tives in separate solutions so that one may be increased 
or diminished without variation, in the dose of the other, 
if it be so desired. For instance, in delirium tremens it 
may be best to continue the bromid and to stop the 
chloral, or to increase the amount of bromid without 
increasing the amount of chloral. However, if it is 
desired. to combine them they may be given as follows: 

gm. or c.c. 

B Chlorali hydrati 51 3 iss 

Potassii bromidi 10 [ or 3 iii 

Syrupi acidi citrici 50 1 

Aquam ad 100| AS ii 

M. Sig. : Two teaspoonfuls, in water, and repeated in two 
hours if deemed advisable. 

Shoemaker suggests the following combination : 

fy Chlorali hydrati 

Potassii bromidi 

Syrupi lactucarii 

Syrupum aurantium ad 

M. Sig. : Two teaspoonfuls in plenty of water, at bedtime. 

When there is pain chloral may be combined with 
morphin to produce sleep,. as: 



m. or c.c. 




10 




3 iii 


15 


or 


3 ivss 


50 






100 




flSii 



gm. or c.c 

R Morphinae sulphatis 

Chlorali hydrati 5 

Glycerini 10 

Aquam ad 50 

M, Sig. : A teaspoonful, in water, as directed., 



gr. iss 
3 iss 
A3 iii 
flSii 



628 PARALDEHYD 

CHLORBUTANOL 

Chlorbutanol, N. N. R., is a white crystalline com- 
pound obtained by reaction of acetone on chloroform. 
It is used like chloral, but claims for its superiority are 
not wholly substantiated. A dose is 5 to 20 grains, dry 
or in capsules. 

PARALDEHYD 

Paraldehyd is a colorless liquid, pungent, irritant, 
and of a disagreeable odor. While theoretically it 
should be a stimulant and its action resemble that of 
alcohol, practically it is such a strong narcotic and 
hypnotic that its soporific and prostating effects over- 
come any stimulant action that it possesses. Its action 
on the skin would be irritant, especially if its rapid 
evaporation were prevented. In mucous membranes it 
causes burning, and if not well diluted irritation and 
even inflammation. It is so active in this respect that it 
is even difficult to swallow it into the stomach without 
choking unless its evaporating and burning properties 
are held in check by iced water. It is so rapidly 
absorbed from the stomach that its effect is sometimes 
almost instantaneous. The heart is quickly stimulated, 
the pulse bounds and throbbing is felt in the head and 
arteries of the neck similar to that produced by a large 
dose of a nitrite, and the patient becomes momentarily 
dizzy and later faint. The dizziness is due to an 
increased cerebral circulation, while the faintness is 
probably due to the dilated blood vessels of the body 
causing slight cerebral anemia. An uncontrollable 
desire to sleep quickly develops and the patient may be 
sleeping soundly in five or ten minutes. How much 
of this sudden sleep is due to an actual narcotic effect 
on the brain, and how much is due to an anemia of the 
brain caused by a rapid dilatation of the blood vessels 
of the body, has not been determined. On account of 
the stimulant effect on the heart and the lack of any 
profound nervous poisoning from the drug, even large 
doses have not produced death, although frequently 
the first symptoms from paraldehyd are so intensely 
disagreeable and disturbing to the patient that he or 
she will refuse to ever take the drug again. Large 
doses, however, can produce a condition of uncon- 



PARALDEHYD 629 

sciousness from which the patient, at least temporarily, 
cannot be aroused. 

It is excreted mostly in the urine, but considerably 
by the lungs, and imparts a disagreeable odor to the 
breath for some hours after the patient awakens. 

The sleep caused by paraldehyd is not protracted, 
and with a therapeutic dose is normal, and the patient 
awakens without any prostrating effects. It is a hyp- 
notic to which the system becomes accustomed, and 
larger doses are required to produce sleep ; also a paral- 
dehyd habit can be formed, the patient not only learn- 
ing to need a hypnotic, but craving the stimulation which 
paraldehyd causes. It seems to have a greater action 
in a smaller dose in young patients than in those that 
have a high blood pressure ; in other words, patients 
who can stand a large dose of nitrites without discom- 
fort will require a large dose of paralydehyd to produce 
sleep. It is not analgesic, and except in large doses 
will not relieve pain, and if the pain is severe its hyp- 
notic action would be counteracted unless the dose 
were excessive. In weakened conditions of the heart 
it is a safer hypnotic than chloral, and is used fre- 
quently in the delirium of serious illness, as pneumonia 
and typhoid, but not always successfully. It is so 
likely to disturb the stomach in serious conditions that 
generally it should not be used. It is frequently used 
as a hypnotic in delirium tremens, and probably acts 
satisfactorily in this disease through its various activi- 
ties, i. e., the throat and stomach irritation is satis- 
factory to the alcoholic patient, the stimulation of the 
heart is not unlike that of alcohol, and if the dose is 
sufficient it may produce the much desired sleep. 
* If a poisonous dose has been taken, or if unexpected 
intense action is developed from a therapeutic dose, the 
treatment would be that of a narcotic depressant poi- 
son and similar to that of chloral. An emetic should 
be administered if the patient is seen soon after inges- 
tion of the drug. The body should be kept warm with 
dry heat, and hypodermatic injections of strychnin, 
camphor and adrenalin solutions should be given. 
Atropin could be used if necessary. 

The official preparation is Paraldehydum, and the 
dose is 2 ex. or 30 minims. 



630 SULPHONAL 

Various menstrua have been suggested in which to 
administer this disagreeable drug, but there is no men- 
struum better than iced water, as : 

gm. or c.c. 
3 Paraldehydi 50 1 or AS ii 

M. Sig. : A half teaspoonful on cracked ice and water at 
bedtime. 

Ordinarily when this drug is administered the patient 
should be already in bed and the room quiet and pre- 
pared for sleep. 

It may also be administered as follows : 

gm. or c.c. 

3 Paraldehydi 501 AS ii 

Glycerini 25 1 or fiS i 

Aquam ad 100| AS iv 

M. Sig. : A teaspoonful, in plenty of water, at bedtime. 

SULPHONAL 

Sulphonal is official under the name of sulphon- 
methanum. It is a synthetic product, and occurs as a 
crystalline, colorless powder, without odor or taste. It 
is almost insoluble in cold water, and but slightly solu- 
ble in alcohol. 

It is a hypnotic, and has no other therapeutic uses. 
It is not irritant to either skin or mucous membranes, 
is but slowly absorbed from the stomach, and hence 
acts but slowly in producing sleep, and the full effect 
of the drug may not be felt for four or five hours after 
its ingestion. It also seems to be so slowly excreted 
that the second dose, taken on the following evening 
will cause a much better and more prolonged sleep 
than did the first dose. It acts chiefly on the cerebfal 
cortex, and produces a sleep resembling natural sleep, 
which lasts from six to eight hours. The patient gen- 
erally awakens without any ill effects, but occasionally 
there is some dizziness, and a feeling of weakness, or 
of general lassitude. It does not act on the peripheral 
nerves, and is not an analgesic. Under its full action 
the reflexes may be diminished, probably by central 
inhibition. It has no marked action on the circulatory 
system, and is excreted in the urine chiefly as ethyl 
sulphonic acid. When large dose? are taken part of it 



SULPHONAL 631 

is eliminated by the intestines, and part may be excreted 
as sulphonal in the urine. 

While death has been attributed to 2.0 gm. (30 
grains) of sulphonal, enormous doses have been recov- 
ered from. It is probable that if a patient were other- 
wise healthy it would take a very large dose of sul- 
phonal to cause death. The symptoms of its overaction 
are profound and prolonged sleep, with a gradually 
failing circulation and respiration. 

Chronic poisoning is not infrequently noted, either 
from the careless use of the drug or from an actual 
sulphonal habit. There is a general loss of strength, 
gastro-intestinal indigestion, often diarrhea, loss of 
weight, and mental sluggishness, or even symptoms 
suggesting general paresis. There may be weakness 
of the legs, disturbed patellar reflexes, and cerebral 
delusions and illusions, and gradual loss of mental 
power. From repeated doses, and especially from pro- 
longed use of sulphonal, the kidneys become degen- 
erated, albuminuria occurs, and the urine is of a 
pinkish or cherry-red color. Although sulphonal may 
cause an actual hemoglobinuria, this discoloration is 
due to a decomposition of the hemoglobin of the red 
blood corpuscles and a production of hematoporphyrin. 

Sulphonal even in a single dose, and frequently when 
doses are repeated, may cause a slight eruption on the 
skin, either papular or scarlatiniform in character. 

The treatment of acute poisoning by sulphonal is to 
hasten the elimination in every way possible, viz., by 
purgatives, and by the administration of large amounts 
of water by the stomach and by the rectum to hasten 
the elimination through the kidneys. If collapse is 
present it should, of course, be treated as usual by dry 
heat and the proper circulatory stimulants. 

Chronic poisoning, or the sulphonal habit, requires a 
long period before health may be restored, and it is 
doubtful if the kidneys ever become again perfect. 
wSleeplessness must be combated by some drug other 
than a synthetic product. General tonics, forced feed- 
ing, massage, hydrotherapy, and fresh air, should all be 
utilized in restoring the patient to health, and such 
treatment and diet should be instituted as is conducive 
to restoring irrigated or damaged kidneys to normal. 



632 TRIONAL 

Sulphonal may be selected as a safe hypnotic in ordi- 
nary insomnia. It will not combat pain, and it is not 
sufficiently depressant to prevent its use in ordinary 
weak conditions of the circulation. It has been used 
considerably in the insomnia of insanity, but the dose 
required for this purpose is large. It should be remem- 
bered that repeated doses on successive days have an 
increasing hypnotic effect, at least for a time. If 
taken for a long period, however, it does cause pros- 
tration and muscle debility and a lack of appetite. 
Also, there is the same danger of forming a habit from 
this drug as from any other hypnotic. It has been used 
in the deliriums of acute febrile diseases, and often 
is efficient and valuable. It is frequently used in alco- 
holic deliriums, but is not so efficient as chloral or 
paraldehyd. It has been employed in spasmodic con- 
ditions as in chorea, epilepsy, and muscle cramps, but 
other drugs are better for this purpose. 

The drug acts so slowly that it is not advisable in 
ordinary insomnia to repeat the dose on the same 
night. Consequently the dose selected should be suffi- 
cient to produce sleep. This is ordinarily 1.0 gm. (15 
grains), best administered in powder, and drunk with 
hot water or hot milk at least four hours before bed- 
time. If the sulphonal is to be repeated on successive 
nights, less than the above dose will generally prove 
efficient. 

If sulphonal is given for sleeplessness and delirium 
during an acute disease, a smaller dose, as 0.50 gm, 
(7y 2 grains) should be given, which can be repeated in 
five hours if the first dose does not cause sleep. It 
may be ordered as follows: 

gm. or c.c. 

R Sulphonmethani S| or gr. lxxv 

M. et fac chartulas, 5. 

Sig. : One powder, with a glass of hot milk, at 5 p. m. 

TRIONAL 

Trional is official under the name of sulphonethyl- 
methanum, and is a synthetic product chemically simi- 
lar to sulphonal, which occurs as colorless crvstals, 
without odor, and of a bitter taste. It is readily solu- 
ble in alcohol, and slightly soluble in water. 



SCOPOLAMIN 633 

Trional is not irritant to the skin or mucous mem- 
branes, and, being more soluble than sulphonal,, is more 
quickly absorbed from the stomach, and consequently 
shows its hypnotic action sooner. It causes sleep, gen- 
erally within an hour, which lasts about six hours. Its 
physiologic action is similar to that of sulphonal. It in 
excreted by the kidneys, and can cause the same dis- 
coloration of the urine as described under sulphonal. 
It is as little liable to cause acute cardiac depression or 
acute poisoning as is sulphonal, but prolonged use can 
cause the same chronic debility and kidney irritation. 

The treatment of acute poisoning, or chronic poison- 
ing, or a trional habit, is the same as described under 
sulphonal. 

Its only use is as a hypnotic, and under the same con- 
ditions as those for which sulphonal is prescribed. It 
has been thought that it would cause less disturbance, 
as it acts more quickly and in a smaller dose than does 
sulphonal. 

The usual dose of trional is 0.60 gm. (10 grains), 
best administered in capsules, with a glass of hot water 
or hot milk, an hour before bedtime, as : 

gm. or c.c. 

B Sulphonethylmethani 3| or gr. xlv 

M. et fac capsulas, 10. 

Sig. : Two capsules, with hot water, an hour before bedtime. 

SCOPOLAMIN 

Scopolamin (hyoscin) is an alkaloid occurring in 
hyoscyamus together with hyoscyamin and hyoscipicrin, 
but in its manufacture is mostly obtained from other 
sources. It is closely allied to atropin, both in its 
chemical constituency and in its physiologic action. 

The official preparation is Scopolamines hydrobromi- 
dum, which occurs as transparent, colorless, crystals of 
a bitter disagreeable taste, soluble in alcohol, and very 
soluble in water. The beginning hypodermatic dose is 
.0003 gm. (1/200 grain). 

The official Hyoscince hydrobrominidum is identical 
chemically and physiologically with the scopolamin 
hydrobromid. 

Scopolamin (hyoscin) acts locally similarly to atro- 
pin, viz., it dulls and numbs the peripheral termina- 



634 SCOPOLAMIN 

tions of nerves, whether in the eroded skin or in 
mucous membranes, causes dryness of the throat, 
benumbing of the tongue, and a diminished secretion 
of saliva. It dilates the pupil more quickly than atro- 
pin, but the dilation does not last so long. 

After absorption its action ordinarily is quite differ- 
ent from that of atropin both on the nervous system 
and on the circulatory system. Although there may be 
a slight period of cerebral excitement, the effect is 
generally hypnotic. This is especially marked when it 
is administered hypodermatically, a dose of 1/100 of 
a grain usually putting a patient to sleep in a few min- 
utes. Occasionally scopolamin causes cerebral excita- 
tion similar to that caused by atropin, and perhaps 
even more active. Such patients show an idiosyncrasy 
against this drug, and it is not of infrequent occur- 
rence, should always be suspected until the patient's 
behavior under the drug has become known. A dose 
of 1/100 of a grain may cause wild excitement and 
delirium which may last for some time unless inhibited 
by a hypodermatic injection of morphin, or the admin- 
istration of bromids or chloral. During such excita- 
tion the pupils are dilated, the throat dry, the face 
flushed, and the heart rapid. 

Unlike atropin, which is a stimulant to the heart and 
a contractor of the blood vessels, scopolamin generally 
has but little such effect, and even an ordinary hypo- 
dermatic dose, 1/200 or 1/100 of a grain, may cause 
some cardiac and circulatory depression. In fact, 
when there is cardiac weakness scopolamin should not 
be administered. This unpleasant debilitating action 
on the heart is sometimes noticed when this drug is 
administered in delirium tremens; consequently, it 
should not be administered to any patient unless the 
circulation is at least fairly good and the patient can 
be at rest in bed. In other words, it is inadvisable to 
administer scopolamin to a delirious patient, when that 
patient must subsequently be moved to a hospital or 
to his home. 

On account of the occasional undesirable stimula- 
tion of the brain by scopolamin and the frequent pro- 
found depression of the circulation that it can cause, 
the beginning dose to any patient whose tolerance is 



SCOPOLAMIN 635 

not known should be 1/200 of a grain hypodermati- 
cally. To repeat, it should be thoroughly understood 
that the action on the circulation clinically is never that 
of atropin. In other words, atropin may be adminis- 
tered in shock ; scopolamin may cause shock. 

The sleep from this drug lasts six or seven hours, 
and may be intensified or prolonged by the coincident 
administration of morphin. A combined injection of 
1/200 of a grain of scopolamin (hyoscin) hydrobromid 
and }i of a grain of morphin sulphate will generally 
cause prolonged and satisfactory sleep. Such a com- 
bination in emergencies is perhaps better than a larger 
dose of scopolamin, but, of course, if scopolamin is to 
be repeated for a time the morphin should not be 
given in combination, lest a habit be formed. On awak- 
ening from a scopolamin sleep there is often slight 
circulatory weakness. This signifies that the drug gen- 
erally should not be administered to a patient as a 
hypnotic if that patient must arise in the morning 
and attend to active business. As a hypnotic it should 
be reserved for the sleeplessness occurring in acute 
conditions. It is often a satisfactory drug to use in 
delirium tremens and in the meningitis of pneumonia 
and typhoid fever. It must not be forgotten, how- 
ever, that a larger dose may be required when there 
is active delirium, and such a dose may be followed 
by circulatory depression. The drug is often of great 
value in the sleeplessness of insanity, whatever the 
type. If for any reason scopolamin is given continu- 
ously for a time the patient acquires a tolerance and 
needs a larger dose than at first to cause sleep. 

Although a combination of morphin and scopolamin 
is now often used as a prelude to ether and chloroform 
anesthesia, it seems inadvisable to give these drugs 
that cause depressant action on the respiratory center 
so that the anesthetist can not decide whether respira- 
tory or cardiac failure is due to the previously given 
drugs or to the anesthetic. If he thinks that the anes- 
thetic is causing the depression he may allow the 
patient to come sufficiently out of the influence of the 
anesthetic to permit shock to occur from reflex nerve 
pain. Morphin and scopolamin are now often adminis- 
tered in sufficient doses to produce anesthesia for 



636 SCOPOLAMIN-MORPHIN ANALGESIA 

operations or for a painless parturition without the 
subsequent aid of an anesthetic. While such use at 
times may be advisable and perhaps may be the best 
method of producing a loss of nerve sensation, it would 
be unwise to consider it universally correct or advis- 
able. 

The best method of administering scopolamin (hyos- 
cin) is hypodermatically, but it is often advisable to 
give it for solution in the mouth or in a teaspoonful of 
water, and for this purpose the ordinary hypodermic 
tablet is the most satisfactory. The dose thus given by 
the mouth should not be larger than the hypodermatic 
dose, viz., 1/200 of a grain. 

Scopolamin has been used as a nerve and muscle 
sedative in paralvsis agitans. The beginning dose for 
this purpose is small, 0.00015 to 0.0002 gm. (1/400 to 
1/300 grain) two or three times a day. The patient 
rapidly becomes tolerant to the drug and requires an 
increase in the dose. It is therefore best, if possible, 
to use the drug only at such specific times as it may be 
necessary to quiet the hand tremor that the patient may 
write his signature. In such small doses, and on 
account of the tolerance he soon develops, the drug 
does not exert its hypnotic influence. It may be 
ordered for this purpose as follows : 

gm. or c.c. 

I£ Scopolaminae hydrobromidi 1003 or gr. 1 /^ 

Aquae menthae piperitae. . . 100| AS in 

M. Sig. : A teaspoonful two or three times a day, as 
directed. 

SCOPOLAMIN-MORPHIN ANALGESIA IN OBSTETRICS 

The history of this method is of interest in showing 
its development. Steinbuchel of Graz (1903) began 
with small doses of morphin and scopolamin in obstet- 
rics and had no unfavorable results ; that is, no dan- 
gerous results. Those who followed him used repeated 
doses of morphin as well as scopolamin — sometimes 
excessively large doses, with the result that there were 
serious consequences, particularly the death of the 
infant. In 1907 a special technic was elaborated by 
Gauss in the clinic of Kronig at Freiburg in Baden. 
The technic of Gauss is substantially as follows : The 



NITRITES 637 

object aimed at is to make the parturient woman forget 
her pains, although she may be conscious of them at 
the time ; the condition known as "twilight slumber'' 
(Dammerschlaf) is produced. The patient is given a 
dose of 1/200 scopolamin and y% grain of morphin. 
In order to test the mental condition of the patient, she 
is shown some object and after an interval of about 
half an hour, this object is again called to her atten- 
tion. If she remembers having seen it before, she is 
not sufficiently amnesic, and an additional dose of 
scopolamin is given. It should be remembered that 
the method of Gauss is not correctly represented by 
the frequent recommendations to use scopolamin- 
morphin for the relief of pain in labor. Let it be 
emphasized that but a single dose of morphin is used. 
In this way the frightful mortality that occurs in 
infants from morphin injections is largely eliminated. 

Scopolamin also has its own dangers. Small doses 
sometimes produce very serious results. There may 
be great disturbances of the nervous system, or of the 
heart and lungs. It is impossible to predict when these 
results may follow its administration and they cannot 
be guarded against. Proprietary preparations con- 
taining fixed quantities of the two alkaloids cannot be 
successfully used to secure the results desired. 

The impression gained from a review of the litera- 
ture is that the present method of obstetric anesthesia 
by scopolamin and morphin is not safe for the child 
and in many cases not safe or successful for the 
mother. It is distinctly a method for use in rare cases 
and invariably in the hospital. 

CIRCULATORY DEPRESSANTS 

NITRITES 

The value of the nitrites seems to be their ability to 
reduce blood-pressure. In some instances an instan- 
taneous reduction is desired ; in other conditions, as in 
arteriosclerosis and chronic nephritis, it is sometimes 
advisable to keep the blood-pressure constantly 
reduced. 

ACTION OF THE DRUG 

The action of amyl nitrite as a vasodilator is instan- 
taneous, and with this action the heart is accelerated 



638 PHARMACOLOGY OF NITRITES 

and the head feels full and throbs. It sometimes causes 
severe headache. It the amount inhaled is considerable 
the patient becomes faint, and always after nitrite of 
amyl has been used the patient should remain at rest 
for some time. The intensity of the action is soon 
over and, therefore, nitrite of amyl is indicated when 
instantaneous effect is desired, as typically in angina 
pectoris, or during the aura of an epileptic seizure. 
In the first instance, it obviates the danger of cardiac 
spasm, and in the second instance may abort the con- 
vulsion. In sudden cardiac failures, as in ether or 
chloroform narcosis, nitrite of amyl has sometimes 
been administered, but for such purposes is rarely 
indicated. 

When a more prolonged vasodilator effect is desired, 
nitroglycerin is indicated, either administered hypo- 
dermatically in soluble tablet where the dose should 
rarely be more than 1/100 of a grain, or a tablet is 
allowed to dissolve on the tongue, or a drop or two of 
the spirit of nitroglycerin, or when slower action is 
desired, swallowed after a meal. Unless the condition 
is one of emergency and the quick stimulating effect 
of nitroglycerin is desired which will immediately be 
followed by dilatation of the peripheral blood-vessels, 
nitroglycerin should be swallowed after a full meal. 
In this way the sudden, intense action with throbbing 
and fulness in the head is obviated. Nitroglycerin may 
be administered, when considerable dilator action is 
desired, every three or four hours, but three times a 
day, or perhaps better, four times a day (i. e., after 
each meal and at bedtime),, is generally the frequency 
that is sufficient to continuously keep a high blood-pres- 
sure slightly reduced. In hypertension in chronic endar- 
teritis or arteriosclerosis it may frequently be noted 
that a small dose acts more satisfactorily than a larger 
one, i. c, many times 1/400 of a grain of nitroglycerin 
will act better than a larger dose. It must be remem- 
bered that such patients do not do well with low ten- 
sion. Nitroglycerin is also very efficient and very 
successful in overcoming cardiac distress and dyspnea 
when there is aortic narrowing, when the left ventricle 
is not weakened. 



PREPARATIONS OF NITRITES - 639 

Nitroglycerin also often relieves insomnia, when 
given at bedtime, by causing enough relaxation of the 
vessels to produce normal anemia of the brain — this 
in old people. Also, many times in continued fevers 
when alcohol seems indicated, nitroglycerin may be 
substituted to cause just sufficient dilatation of the 
surface vessels to aid in diminishing the temperature, 
which is one of the valuable actions of alcohol in 
fever. 

It should be emphasized that the disagreeable sud- 
den and unpleasant effects of nitroglycerin may be 
obviated by giving smaller doses and by administering 
it after a meal and swallowing it with water ; in other 
words, not allowing the medicine to be absorbed from 
the mouth. 

The value of nitroglycerin in asthma to abort or to 
shorten the acute attack is well understood. The dose 
selected, perhaps 1/100 of a grain, should be admin- 
istered every fifteen minutes until the severe headache 
or frontal throbbing is relieved, at which time the 
bronchial spasm will generally have relaxed. 

While nitroglycerin is not so quick in its action as 
nitrite of amyl, and is more prolonged, its action is not 
so lasting as that of sodium nitrite, hence sodium 
nitrite is often used in its place. This drug should be 
administered three times a day, after meals, as : 

gm. or c.c. 

fy Sodii nitritis II or gr. xv 

Sodii bicarbonatis 20 1 3v 

M. et fac chartulas, 20. 

Sig. : One powder, three times a day, after meals. 

If the above alkali is not indicated as it often is in 
patients who need nitrites, any simple powder, as sugar 
of milk or any other combination, may be made that is 
deemed advisable. 

PREPARATIONS IN USEFUL DRUGS 

Amylis Nitris, nitrite of amyl, is a very volatile 
liquid which is administered by inhalation only, and 
the dose is a few drops on the handkerchief, or a 
glass capsule (or "pearl") is broken in a handkerchief 
and thus inhaled. 

Spiritus (ilycerylis Nitratis, the spirit of nitro-gly- 
cerin, or glonoin, or trinitrin, as it is also termed, 



640 MAGNESIUM OXID 

is a 1 per cent, solution of nitroglycerin, and the dose 
is one or two drops, administered in water. 

Sodii Nitris, sodium nitrite, occurs in white opaque 
masses or as crystals. It is odorless and has a mild 
saline taste. It quickly changes to the nitrate on expo- 
sure to the air and is then unfit for use. It is very 
soluble in water, and the dose is 0.065 gm. 1 grain). 

Nitroglycerin is also offered in tablet triturate form, 
the dose ranging from 1/400 to 1/50 of a grain. 

MAGNESIUM OXID 
MAGNESIA^ CALCINED MAGNESIA, OR LIGHT MAGNESIA 

Magnesium oxid is a light, fine white powder, odor- 
less and practically tasteless. It is insoluble in alcohol 
and water, but soluble in dilute acids. 

It has no local action on the skin other than that of 
a dusting powder. In the stomach it acts as an ant- 
acid, combining and neutralizing any acid that is pres- 
ent, and the resulting combination causes it to act 
mildly on the bowels as a laxative. 

In acidity of the stomach, whether from too much 
hydrochloric acid or from lactic acid fermentation, it 
is a valuable antidote, relieving the symptoms of pain, 
burning, distress and acid eructations almost immedi- 
ately. 

In intestinal indigestion in children, when there is 
intestinal flatulence and the feces are more or less acid 
as shown by hyperemia and irritations about the anus, 
magnesia is good treatment. 

Magnesia is a valuable laxative for bottle-fed babies, 
as it is tasteless and is really administered in milk. 
A good preparation for this purpose is the milk of mag- 
nesia of the National Formulary. 

The laxative action of magnesia may be increased 
by administering it with a little lemon juice or lem- 
onade. 

As magnesia forms insoluble compounds with solu- 
ble arsenic and mercury salts, it may be used as an 
antidote in poisoning from these metals, and a specifi- 
cally recognized in its antidotal action of arsenic poi- 
soning under the name of Ferri Hydroxidum cum 
Magnesii Oxido, U. S. P., i. e., the "arsenic antidote." 
If more active alkalies are not at hand, magnesia may 
well be used in poisoning with acids. 



ADMINISTRATION OF MAGNESIUM 641 

As a cathartic magnesia is not sufficiently active to 
warrant its use, the dose required being disagreeably 
large. As a gentle laxative, given two or three times 
a day, when there is an abnormal acidity of the stom- 
ach, it is certainly of advantage. 

The dose of magnesia (magnesii oxidum) while 
stated to be 2 gm., is too much powder ordinarily to be 
taken at one dose, and, as above stated, if a cathartic 
is needed, other drugs should be used. As a gentle 
laxative three times a day, from 0.30 to 0.50 gm. (from 
5 to 10 grains) is often efficient, and if there is hyper- 
acidity of the stomach, it is better given after meals. A 
good method of administering magnesia is in milk, 
or in a little effervescing water, as carbonated water 
or vichy. Of course, magnesia could be put into 
wafers or konseals. 

ADMINISTRATION 

Magnesia may be administered as follows : 
For gastritis with constipation : 

gm. or c.c. 

I£ Bismuthi subnitratis 201 or 3v 

Magnesii oxidi 10 1 3 iiss 

M. et fac chartulas, 20. 

Sig. : One powder, three times a day, before meals. 

If there is hyperacidity of the stomach: 

gm. or c.c. 



3 iiss 
3 iss 
3 iiss 



R Bismuthi subgallatis 10 

Magnesii oxidi 6 

Sodii bicarbonatis 10 

M. et fac chartulas, 20. 

Sig.: One powder, three times a day, before meals. 

Or, if there is much gastric flatulence : 

gm. or c.c. 

R Bismuthi subnitratis.... 20 1 3v 

Magnesii oxidi 5| or 

Carbonis ligni aa 5 1 gr. lxxv 

M. et fac chartulas, 20. 

Sig. : One powder, three times a day, after meals. 

Or: 

gm. or c.c. 

B Sodii bicarbonatis 10 1 or 3 iiss 

Magnesii oxidi 6] 3 iss 

M. et fac konseal, 20. 

Sig. : A wafer, three times a day, after meals. 



642 CATHARTICS 

As a morning laxative : 

gm. or ex. 

I£ Magnesii oxidi 15| or 3 ss 

M. et fac chartulas, 10. 

Sig. : One powder, in a glass of lemonade, before breakfast. 

CATHARTICS 

GENERAL CONSIDERATIONS 

Cathartics may be subdivided into laxatives, purges, 
salines, and irritants or drastics. The object for which 
a cathartic is used determines from which class the 
drug should be selected. The main difference between 
laxatives, purgatives, salines and irritants is that the 
members of the first three classes can rarely cause, 
even in large doses, anything more than free, profuse 
catharsis. The drugs under the irritant class can 
cause, sometimes even in small doses, irritation and 
even inflammation of the intestines, and an actual 
enteritis. 

The indications for the use of a cathartic are: 1, 
to unload the bowels ; 2, to relieve constipation ; 3, as 
an eliminant ; 4, to lower blood-pressure ; 5, to remove 
edema or exudates. 

1. To Unload the Bowels: An evacuant should be 
given to clean out the intestines when there is an irri- 
tant in the bowels, as in acute intestinal indigestion; 
in intestinal colic, and in acute diarrhea. If the patient 
is seen in the evening, the best purgative is, perhaps, 
calomel, in a dose of from 0.10 to 0.30 gm. (2 to 5 
grains), followed in the morning by a saline; or if a 
quicker action is desired, especially if the patient is 
seen in the daytime, a proper dose of Epsom salt, 
citrate of magnesium, a seidlitz powder, or a glass of 
some cathartic mineral water is the best treatment. 
One of the most valuable purgatives is castor oil, espe- 
cially for children. But perhaps there is no better 
treatment for a complete cleansing of the bowels than 
a dose of calomel combined with 1 gm. of bicarbonate 
of soda, with the withdrawal of all food for a number 
of hours, and with a powder of bismuth (bismuthi 
subnitras) and salol (phenylis salicylas) for a series 
of doses, as bismuth 1 gm. (15 grains) and salol 0.30 
gm. (5 grains), every two hours, for ten doses. After 
a longer or shorter interval, from ten to twenty hours, 



CATHARTICS FOR CONSTIPATION 643 

of abstinence from food, a bland, corrected diet should 
be instituted. 

Rarely in children with intestinal indigestion small 
doses of calomel, as from 1/20 to 1/10 of a grain every 
hour until there is green purging, is good treatment. 
The calomel is supposed to have an antiseptic action in 
the bowels. If a minute portion of it is changed into 
corrosive sublimate as it passes through the stomach, 
some antiseptic action occurs. Such chemical change 
is, however, undesirable on account of causing irrita- 
tion of the stomach, and nausea and vomiting. These 
small doses of calomel also cause intestinal irritation 
and often a troublesome diarrhea, and besides, the 
cleaning out of the bowels by any such treatment is 
slow. There is also danger of producing salivation and 
a good deal of weakness. In other words, much as 
such treatment is lauded- by many clinicians, it is often 
objectionable, and, generally, if calomel is to be admin- 
istered it should be given, in the proper dose for the 
age and condition, to act as quickly and completely as 
possible. 

In obstinate constipation saline cathartics or various 
combinations of the more active cathartic vegetable 
drugs are needed. Before giving strong drastic drugs, 
however, especially such as produce irritation or much 
peristalsis, a decision must be made that there is no 
obstruction ; in other words, that the condition is not 
an obstipation. If there is obstruction of any kind, 
active cathartics will make the condition worse. 
Reliance, in these conditions, should be on large colon 
injections of warm water or oil, and if unsuccessful, 
surgical procedure. It is well to begin the treatment of 
all acute diseases, especially infections, with a clean- 
ing out of the bowels by means of some simple purge. 
The best purges are as follows : Calomel, castor oil, 
a saline cathartic. The saline cathartics are : Mag- 
nesium citrate, magnesium sulphate, potassium and 
sodium tartrate, seidlitz powder, sodium phosphate, 
sodium sulphate. Of course, a large dose of any laxa- 
tive will act as a purge. 

2. To Relieve Constipation: In chronic constipation 
laxatives only should be used ; never the strong cathar- 
tics or purgatives, and the dose should be just sufficient, 



644 OTHER USES OF CATHARTICS 

with a properly regulated diet, cold morning sponging 
of the body, abdominal massage, and physical exercises, 
such as walking or outdoor games or athletic work, and 
perhaps abdominal muscular exercises, as, altogether, 
to cause one good movement of the bowels a day. 

If there are hemorrhoids, such drugs as cause pelvic 
congestion should be avoided. The s'ame is true in 
pregnancy and in pelvic inflammations. Aloes and 
rhubarb, unless in small doses and combined with 
some modifying drug, are perhaps well avoided when 
these conditions are present. It is sometimes best to 
give a small dose of a laxative three times a day, after 
meals, instead of once a day, viz., after supper or at 
bedtime, the object being ordinarily to have a move- 
ment of the bowels directly after breakfast, which is 
the most convenient time and the best time for most 
people. This method of administering a small dose 
of a laxative three times a day is most satisfactory 
with a preparation of rhamnus purshiana (cascara 
sagrada). 

If a patient has hemorrhoids or rectal pains, it is 
often a good plan to cause a movement of the bowels 
just before going to bed, as this precludes the proba- 
bility of a fecal mass in the rectum causing congestion 
all night. If there is plethora, liver or kidney insuffi- 
ciency, or obesity, a saline laxative in the morning 
before breakfast is the best treatment. 

The best drugs to use as laxatives, and perhaps in 
the order of preference, are as follows : Cascara 
sagrada, aloin, podophyllum, rhubarb, natural spring 
salts, Rochelle salt, Epsom salt, glauber salt, magnesia, 
sulphur. 

3. As an Eliminant : In all toxemias, uremia, dia- 
betic coma, blood poisoning of all kinds, quickly acting 
cathartics, as croton oil, elaterium, compound jalap 
powder, Epsom salt (and the activity is in the order 
named) are indicated. If a purgative is to be daily 
repeated, the milder salines should be used. 

4. To Lozver Blood-Pressure: When there is cere- 
bral congestion or pressure (in apoplexy, or when there 
is danger of it), the purgatives that cause large, watery 
stools, thus relieving arterial pressure, are indicated. 
The blood-pressure in the head is always less than that 



CASCARA SAGRADA 645 

of the rest of the system, hence the lower the systemic 
pressure, the lower that in the head. Saline laxatives 
are generally the best for this purpose, and should be 
given concentrated, or, if the action must be as soon as 
possible, a drop of croton oil in a little granulated sugar 
on the tongue is the best treatment. 

In advanced arteriosclerosis a daily laxative, com- 
bined wuth a proper regulated diet and such other medi- 
cation as is indicated, is good treatment. 

5. To Remove Edema or Exudates: A purge that 
causes watery stools is indicated when we wish to 
remove edemas and exudates. As many such cathar- 
tics, notably elaterium, are very depressing to the heart, 
they should be used with care. A concentrated solu- 
tion, in proper dose, of one of the saline cathartics, is 
generally satisfactory, and to reap the most advantage 
from the. action of such a solution the liquids taken 
should be restricted. Drastic cathartics or irritants 
are: Colocynth, croton oil, elaterium, jalap. 

CASCARA SAGRADA 

Cascara sagrada was so named by the Spanish, and 
means sacred bark. It is official under the name of 
Rhamnus Purshiana, and is the dried bark of a small 
tree growing on the Pacific Coast. 

PREPARATIONS IN USEFUL DRUGS 

Extractum Rhamni Purshiance. Dose, about .20 
gm. (3 grains). 

Fluid extractum Rhamni Purshianee. Dose, 1 c.c. 
(15 minims). 

Fliiidexcractum Rhamni Purshiance Aromaticum. 
Dose, 1 c.c. (15 minims). 

All these preparations taste bitter except the last, 
and the real dose of any one of them is enough, the 
amount depending on its frequency and the results. 
Many preparations on the market are almost worthless 
as laxatives, as the bark must be long kept and the 
preparations carefully made. The liquid preparations 
are always the most active, and act as slight stimulants 
to the mucous membrane of the stomach, hence act 
rather as bitter tonics. The extract is often dried and 
furnished in tablets which are rendered tasteless by 



646 PODOPHYLLUM 

coating. If these tablets are properly made, and con- 
tain a good preparation of cascara, they are efficient. 
If a cascara preparation or cascara tablet produces 
rectal irritation, there is probably some other ingredi- 
ent than cascara in it to render it active. As pure 
cascara is not astringent and not irritant to the bowels, 
and can cause no irritation or congestion in the pelvis, 
it is not contraindicated in hemorrhoids or in preg- 
nancy. 

It cures constipation perhaps as much by causing a 
daily movement of the bowels and thus creating a 
proper intestinal habit as by any curative properties 
that it may possess. The repeated taking of cascara 
does not create a tolerance, and generally the dose 
may be gradually diminished. Hence, in most instances 
this drug is the best laxative to use in chronic consti- 
pation. Whether it is best to give a small dose three 
times a day or a larger dose once a day, depends on the 
result of a careful study of the individual patient. 
After the amount necessary has been determined, week 
by week this dose may be diminished until finally, by 
the aid of proper diet, exercise, etc., the constipation 
becomes cured. 

PODOPHYLLUM OR MAYAPPLE 

Podophyllum is the dried rhizome of a perennial 
herb which grows in the woods of Canada and northern 
and middle United States, and is sometimes called wild 
mandrake and umbrella plant. It contains besideS 
starch, a resin (4 to 5 per cent.), a gum, a fixed oil 
and gallic acid. The active principle is contained in the 
resin, and is called podophyllotoxin, to which is due 
the purgative properties of the drug. The resin also 
contains podophyllinic acid. 

The drug is practically without odor, but has a bit- 
ter, acrid taste. It is slightly irritant to the skin, and 
decidedly so to mucous membranes, and, therefore, is 
slightly stimulant to the stomach mucous membrane, 
but acts mostly on the intestinal canal, causing increased 
peristalsis. Its action is very slow, taking from ten 
to fifteen hours to cause a movement of the bowels. 
There may be some griping pains, perhaps accompa- 
nied by a little nausea and rarely vomiting. The 



ALOES 647 

movements are soft, and if the drug has been taken 
alone, there may be several. In proper combinations 
only one good movement a day occurs, making this 
drug valuable as a laxative. It seems to cause an 
increased output of bile, and, therefore, stimulates the 
activity of the liver. It also probably reflexly or 
otherwise stimulates the other digestive organs. As it 
can cause considerable griping and irritation of the 
intestines, even to causing blood-stained stools, the 
drug should not be used as a cathartic. As it seems to 
be active in the duodenum and a stimulant to the liver, 
it has been classed as a cholagogue. Its irritant action 
should class it with the irritant or drastic cathartics, 
although its best use is in small doses in combination 
with other mild cathartics as a laxative. Consequently 
its best use is in chronic constipation. 

The most active preparation is the resin, which 
should be combined with other slow-acting cathartics, 
as aloes, rhubarb or colocynth. It should not be 
given with cathartics that act quickly, as it would then 
either be useless and pass off without any action at all, 
or would cause irritation of the bowels and movements 
after the quicker acting cathartic had finished its work. 
It should be remembered that this drug is an irritant, 
and consequently should not be administered when 
there is inflammation of the intestines, and should 
probably not be given to children. Its overaction has 
caused death. Besides its combination with other slow- 
acting cathartics, a drug to control its tendency to 
cause griping is indicated. In other words, it is well 
combined with hyoscyamus or belladonna, and some- 
times with an aromatic-like ginger or capsicum. 

The full dose of the drug itself is 0.5 gm, or 7y 2 
grains, but as there is occasionally a susceptibility of 
patients to overaction from this drug, the beginning 
dose should be smaller than the above. The best prepa- 
ration is : 

Resina Podophylli (podophyllin), the resin of 
podophyllum. The laxative dose is 0.005 gm, or 1/12 
grain. 

ALOES 

The official aloes is the inspissated juice obtained 
from the leaves of various species, and in the crude 



648 ALOES AS A LAXATIVE 

state occurs as brownish masses. Aloes and all its 
preparations have a bitter taste. 

An active principle called aloin has been obtained 
from aloes. While aloin is less certain in its effect than 
the purified aloes, it is still generally satisfactory as a 
laxative. The purgative principle of aloes is said to 
reside in a principle called emodin, which is probably 
set free in the alkaline secretions of the upper intestine. 
The presence of alkalies seems to be necessary for the 
activities of this purgative principle, and experience 
seems to teach that many times combination with iron 
renders the aloes more effective. If a liquid prepara- 
tion of aloes were administered before meals, if the 
amount were small, it would act as a bitter tonic or 
stomachic. The amount, however, must be small, or 
it would cause nausea. 

Aloes stimulates the activity of the muscular coat of 
the intestine, thus increasing peristalsis, and this action 
seems to be principally on the large intestine. The 
movements that aloes causes are soft and dark colored, 
and the discharges are ordinarily not watery. Aloes 
seems to have a predilection for irritating or congest- 
ing the rectum, and seems to cause congestion gener- 
ally of the pelvic organs. For this reason it is gen- 
erally inadvisable to use aloes as a laxative when there 
are hemorrhoids, rectal or colon irritations, or inflam- 
mation of the pelvic organs, or in pregnancy. Its 
stimulant action to the mucous membrane of the intes- 
tines probably reflexly increases the secretion of the 
liver and pancreas and probably the intestinal glands. 
Owing to its tendency to cause irritation sufficient to 
produce griping, the pain from which is referred to the 
umbilical region, it is generally inadvisable to use 
aloes in any form as a cathartic, unless it is in com- 
bination with some more active drug. 

ALOES AS A LAXATIVE 

The most important use, then, of aloes is as a laxa- 
tive, which means a daily dose sufficient to produce 
one daily movement of the bowels. As the action of 
aloes is slow, it taking from eight to ten hours or 
longer to cause a movement of the bowels, the best 
time to administer this drug is after supper. With 



PREPARATIONS OF ALOES 649 

some patients a small dose of aloes or aloin three 
times a day, after meals, is successful, but generally 
the one sufficient dose after supper is the best method 
of treating chronic constipation. As aloes or aloin alone, 
as above stated, is likely to produce griping for some 
little time before the bowels are moved, it is generally 
best to combine the aloes with some drug or drugs that 
correct such unpleasant action. The most effective 
drug for this purpose is belladonna, the dose of which 
should not be large, as there is frequently idiosyncrasy 
against belladonna, and if one pill or tablet of the 
combined aloes and belladonna does not produce satis- 
factory movements, the dose could not be doubled with- 
out danger of overaction from the belladonna. A 
small dose of strychnia added to the aloin pill or tablet 
is often advisable, as it causes a little more activity of 
the intestines. It is also often well to add a little ipe- 
sac, which also stimulates the upper part of the intes- 
tine and the secretion or excretion of bile. 

PREPARATIONS IN USEFUL DRUGS 

Aloe: The preparation used is an extract from the 
leaves of various spices of aloes, and contains aloin, a 
resin, a trace of gallic acid, and volatile oil to which 
it owes its odor. The dose is 0.25 gm, or 4 grains. 

Extractum Aloes is a powder, the dose of which 
is 0.10 gm., or 2 grains. 

Aloinum (Aloin) is the active cathartic prinicple 
of aloes, and the dose is 0.02 gm., or ^ of a grain. 

The dose of aloes, or any of its preparations, or its 
active principle, is always enough, and no more than 
enough to cause one good movement a day. 

In the treatment of chronic constipation aloin is 
frequently given in doses of from 0.005 to 0.02 gm., 
or Vio t0 J A £ ram -> m combination with extract of 
belladonna and strychnin. 

gm. or c.c. 



0015 gr.%o 

02 or gr.V 3 
006 gr. lAo 



B Strychninae sulphatis 

Aloinae 

Extracti belladonnae 

M. et. fac one pill or capsule. 
Sig. : Take one after supper or at bedtime; if at bedtime, 
with plenty of water. 



650 PHARMACOLOGY OF RHUBARB 

RHEUM— RHUBARB 

Rhubarb is officially the dried rhizome of a plant 
growing in China or Thibet. The rhubarb cultivated 
in this country does not seem to possess cathartic quali- 
ties. The root or powdered substance has a character- 
istic aromatic odor, and a bitter, astringent taste, and 
its cathartic principles may be extracted by water and 
alcohol. Rhubarb contains, according to Culbreth, 
about 5 per cent, of chrysophanic acid, emodin, which 
is the active principle of several vegetable cathartics, 
two other principles called rhein and rhabarberon, a 
glucosid, a tannic acid called rheotannic acid, resins, 
several coloring principles, and a varying quantity of 
rosette-shaped crystals of oxalate of calcium. 

If taken into the mouth, although it is somewhat 
astringent, its bitter taste increases the flow of the 
saliva, and in small amounts, increases the appetite 
and improves digestion, acting as a stomachic. In 
larger doses it causes several loose movements of the 
bowels, probably due to irritation of the mucous mem- 
brane of the intestine, which directly or reflexly 
through irritation of the nerves increases peristalsis. 
This increased peristalsis causes the food to pass more 
rapidly through the intestine, and this carries with it a 
larger amount of bile than usual, and, therefore, the 
feces are soft and contain an increased quantity of 
bile. Rhubarb increases the secretion of the intestinal 
glands, and probably also the glands of digestion, and 
this may also be a cause of the increased intestinal 
activity. It is a slow-acting drug, and may cause move- 
ment of the bowels anywhere from six to twelve hours 
after its ingestion, depending on the size of the dose, 
the preparation taken, and the amount of food in the 
stomach and intestines. If rhubarb is given alone (not 
combined with other drugs) it generally causes more or 
less griping. On account of the tannic acid which 
rhubarb contains, the catharsis from one dose is fol- 
lowed by sufficient astringent action in the intestines 
to cause future constipation. Hence, unless rhubarb 
is given to clean out the intestines when there is diar- 
rhea, it is generally inadvisable to give it for consti- 
pation unless it is combined with some other laxative 
drug. 



EXCRETION OF RHUBARB 651 

ITS EXCRETION 

It is excreted with the feces ; in the urine, which is 
slightly increased in amount; in the perspiration, and 
in the milk. The feces are yellowish-brown or dark 
brown in color, and the urine of patients taking rhu- 
barb may be of a reddish color. Such urine becomes 
purplish-red if an alkali is added to it, which proves 
that the dark color is not due to bile. The milk of 
nursing mothers may be yellowish in color, have a bit- 
ter taste, and a laxative action; therefore, nursing 
mothers should rarely be given rhubarb. Occasionally 
after the administration of rhubarb there is an eruption 
on the skin which, if urticarial in type, is doubtless due 
to the irritation of the intestinal mucous membrane, 
but if macular or vesicular, as has at times been 
noted, is probably due to the irritation it causes during 
its excretion by the sweat glands. 

The ability of rhubarb to cause catharsis and then 
stop its action and not continue to cause a diarrhea 
renders it useful to unload the intestine in gastrointes- 
tinal disturbances in children. In conditions of indi- 
gestion, with sluggishness of the bowels, loss of appe- 
tite, and general debility, rhubarb is, perhaps, the best 
drug to use, as it is a bitter tonic, a stimulant to the 
digestion, and a laxative to the bowels, with a general 
toning up of the intestines. If castor oil is deemed 
inadvisable, and the prostrating effect of a dose of 
calomel is not desirable, in the beginning of the treat- 
ment of diarrhea, especially in children, rhubarb makes 
an efficient cathartic. This drug is also often given in 
small doses three times a day, in various combinations, 
to improve digestion and to stimulate the intestines ; 
for this purpose it is often combined with bicarbonate 
of sodium. As a laxative in the treatment of consti- 
pation it is much used, but perhaps best, as previously 
stated, in combination with other laxative drugs. 
When there is intestinal indigestion, with too frequent 
movements of the bowels, with a tendency to loose 
movement directly after a meal, small doses of rhu- 
barb, perhaps, combined with ipecac and sodium bicar- 
bonate, are effective in correcting the condition. If 
there is a condition of plethora, or if depletion is 
desired, or free watery movements, rhubarb is not the 



652 JALAP 

cathartic to use. Rhubarb root is furnished in pow- 
dered form, and the cathartic dose is 1 gm., or 15 
grains. 

PREPARATIONS IN USEFUL DRUGS 

Extr actum Rhei: Dose, 0.25 gm., or 4 grains. 

Syrupus Rhei Aromaticus: This contains 15 per 
cent, of aromatic tincture of rhubarb and 1 per cent, 
of potassium carbonate. The dose is 10 c.c, or 2 
fluidrams. 

Tinctura Rhei Aromatica: This contains, besides 
20 per cent, of rhubarb, 4 per cent, of cinnamon, 4 per 
cent, of cloves, 2 per cent, of nutmeg, and 10. per cent, 
of glycerin. The dose is 2 c.c, or 30 minims. 

JALAP 

Jalap is the dried, tuberous root of a climbing vine 
which grows on the eastern slope of the Mexican 
Andes, and is also cultivated in India. It is named 
after Jalapa, or Xalapa, a city of Mexico. It has a 
slight smoky odor, and a sweetish and mildly acrid 
taste. The root yields about 8 per cent, of a resin 
which consists of jalapin and a glucoside, convolvulin, 
or jalapurgin. 

The purgative action of jalap seems to be induced by 
the action of the bile, hence it begins its activity in the 
duodenum. It causes congestion of the mucous mem- 
brane of the intestines, probably increases the secre- 
tion of the intestinal glands, peristalsis is increased, 
and profuse, watery discharges are the result. There 
is often pain, and sometimes griping and vomiting. It 
seems to be less of an irritant than gamboge, podophyl- 
lum or scammony, but excessive doses will produce 
continuous purging. It causes a movement of the 
bowels in from three to four hours. It does not cause 
congestion of the pelvic organs or of the rectum, and 
is perhaps the mildest of the resinous cathartics. As 
it cannot be detected in the urine, it is probably not 
absorbed, and as it is difficult to detect it in the stools, 
it is evident that it is partly or completely oxidized. 

Jalap is a very useful cathartic, especially when it 
is desired to cause absorption of effusions. It is espe- 
cially indicated for this purpose in ascites and in gen- 
eral anasarca, whether from cardiac insufficiency, renal 



JALAP IN DROPSY 653 

disease or cirrhosis of the liver. It is also indicated 
when the brain is to be relieved of a too high blood- 
pressure, or when there is congestion of the brain, in 
meningitis. It is valuable in hypertension, and is espe- 
cially useful when there is venous engorgement from 
failure of the heart in dilatation in valvular disease, 
or in a failure of the right side of the heart from 
emphysema. When any of these indications are to be 
met by the use of jalap it should be remembered that 
the intake of liquids should be restricted, that the pro- 
fuse watery discharges may so deplete the blood as to 
cause it to resorb the water that it finds in the tissues 
or exudates in cases of dropsy, and in cases of venous 
engorgement from cardiac insufficiency, that it may 
relieve the heart of excess of fluid so that the hypo- 
static congestion may be relieved. 

ITS VALUE IN DROPSY 

Jalap is also often the drug selected to increase the 
excretion of toxins by the intestines in renal insuffi- 
ciency and when uremia is present or impending. In 
this instance, if dropsy is not present, considerable 
water may perhaps be taken to aid the dilution of the 
toxins in the blood and to promote the excretion by the 
skin as well as to increase the watery evacuations by 
the intestines. In other words, jalap, in three or four 
hours produces watery stools, causing considerable 
excretion of toxins from the blood, does not cause 
much irritation of the intestines, and if the dose is not 
too frequent, causes but little prostration.- Its taste 
is not unpleasant, and, therefore, it rarely disturbs the 
stomach, and for this reason is often selected as a pur- 
gative in connection with anthelmintics when such are 
needed to remove intestinal worms in children. 

The preparation of jalap most frequently used is: 
Pulvis Jalapce Compositus, U. S. P., the compound 
powder of jalap, which contains 35 per cent, of 
jalap and 65 per cent, of potassium bitartrate (cream 
of tartar) . The adult dose is 2 gm. (30 grains) . This 
may be repeated in five hours if there are no results. 
When necessary, this preparation may be given every 
morning for several days without causing prostration 
or intestinal irritation. 



CROTON OIL 

Oleum HgUi, U. S. P. (genitive, olei tiglii), is a 
yellow, somewhat viscid, fixed oil expressed from the 
seeds of the fruit of a small tree which grows in 
Southern Asia and the Philippine Islands. The seeds 
contain from 30 to 40 per cent, of this oil. The oil 
contains glycerides of various fatty acids, crotonol 
(the vesicating croton resin), and crotonolic (or cro- 
tonoleic) acid (closely allied to oleic and recinoleic 
acid). The croton resin is soluble in alcohol. 

Croton oil is burning and acrid in taste, and an irri- 
tant to the skin and mucous membranes. On the skin 
it produces redness, papules passing into vesicles, and 
finally into pustules, which in healing leave white 
scars. Croton oil has been classed, for this action on 
the skin, as a "pustulent." Occasionally it may cause 
a general eruption resembling small-pox. Sometimes 
enough has been absorbed from the skin to cause 
purging. 

When taken internally, unless very dilute, it is irri- 
tant to the stomach and intestines. It congests the 
mucous membrane of the intestines and increases peri- 
stalsis, causing copious stools accompanied by griping 
pains and a good deal of burning and irritation of the 
rectum and anus. It acts rapidly, a drop or two on the 
tongue causing a stool in one or two hours. 

Large doses cause violent purging, griping, vomiting 
and collapse, and a few drops have been known to 
cause death. If it has been taken by mistake, a quickly 
acting emetic is indicated, with later mucilaginous, 
soothing drinks and a hypodermatic dose of morphin. 
If it has been in the stomach long enough to cause 
severe purging, the treatment is that of acute enteri- 
tis, and the collapse should be treated as usual, with 
external heat and cardiac stimulants. 

Croton oil is used when a quickly acting cathartic 
is indicated, especially when there is difficulty in caus- 
ing the patient to swallow, and a rectal injection of a 
cathartic is inefficient or too slow. Consequently, cro- 
ton oil is used in uremia and in the coma of apoplexy 
where it is deemed advisable to reduce the blood- 
pressure by purgation. It has been used in the con- 
stipation of lead poisoning and in other obstinate con- 



ELATERIN 655 

stipation, but it should be used with great care lest 
intestinal obstruction be present. It may be used at 
times in the constipation of maniacal patients who 
refuse to take other medicine, as the dose of this is 
so small it can be more readily administered. 

The dose of croton oil is one or two drops, and is 
well administered in a bread pill, made at the time, 
if the patient is able to swallow. If the patient can 
not swallow, a drop or two may be put on a little 
granulated sugar and this put into the patient's mouth, 
or, if necessary, a single drop may be placed on the 
back of the tongue. In conditions in which it is indi- 
cated a drop may be repeated every hour for several 
doses until purging takes place. It will rarely take 
more than two or three doses. Minute doses of cro- 
ton oil are sometimes added to laxative pills to make 
them more active. This is inadvisable, however, as 
the tendency, as previously stated, of irritant cathar- 
tics either to cause inflammation of the intestines or 
at least increase the tendency to constipation should 
preclude their use.. 

Croton oil should not be administered to children, 
to debilitated patients, or to pregnant women except 
in desperate cases of uremic poisoning. Also gastro- 
intestinal inflammation or peritonitis should prohibit 
its use. 

ELATERIN 

Elaterin is a neutral, active principle obtained from 
the juice of a fruit (a cucumber-like affair) of a trail- 
ing vine which grows in the countries around the 
Mediterranean Sea. One hundred of these cucumbers 
yield only a gram (15 grains) of elaterin, and it takes 
about eighty pounds of them to produce thirty grams 
(an ounce). Elaterium, or the dried juice of the 
cucumber, occurs in small, grayish fragments or 
masses, and has a tea-like odor and an acrid taste. 
Owing to its adulteration and variation in strength the 
elaterium as such is not now recognized in the Pharma- 
copeia, but its active principle, elaterin, is extracted, 
of which the juice contains from 25 to 35 per cent. 
Elaterin occurs in small white scales or crystals, is of 
acrid bitter taste, is without odor, is insoluble in water, 
and but slightly soluble in alcohol. 



656 INDICATIONS FOR ELATERIN 

ITS ACTION 

It is irritant to the skin and mucous membranes, and 
frequently causes ulceration of the fingers and eyes 
of those working with it. Internally its action resem- 
bles that of colocynth, but it is far more powerful. 
In small doses it acts as a stimulant to the gastrointes- 
tinal mucosa, increasing its secretion. It is also a 
stimulant to the pancreas and liver, perhaps reflexly. 
In larger doses it is irritant to the intestine, producing 
profuse watery stools, usually accompanied with grip- 
ing and nausea, and occasionally with vomiting. 
Elaterium is one of the most powerful hydragogue 
cathartics, and large doses can produce dangerous 
prostration and even death. Elaterin acts when used 
hypodermatically, but is much more efficient when 
given by the mouth, as the bile seems to render it more 
active. 

INDICATIONS 

Elaterium is indicated when it is advisable to pro- 
duce profuse serous discharges from the intestines, and 
has been used for many years in dropsies. It is espe- 
cially valuable when there is effusion in the serous mem- 
brane cavities (pericardial, pleural and peritoneal cav- 
ities), and it is often used successfully when there 
is general anasarca. Frequently diuretics will not act 
efficiently until free watery catharsis has relieved the 
pressure from exudates. Whenever this drug or any 
other is used to relieve dropsies it must be remem- 
bered that the intake of water in any form must be 
diminished. Elaterium has long been used in uremic 
conditions, whether there is dropsy or not, and it has 
often seemed that it relieved cerebral symptoms better* 
than any other hydragogue cathartics. It has been 
thought that it caused the elimination by the intestines 
of more of the products of metabolism, that the kid- 
neys could not excrete, than any other cathartic. It 
has also been used to relieve cerebral and pulmonary 
congestions, acting as a revulsant. However, in cere- 
bral congestion a quicker acting drug, as croton oil, 
is often better, and in dangerous acute pulmonary con- 
gestion any quickly hydragogue cathartic, as magne- 
sium sulphate, will act as well, or better still, vene- 
section as indicated. 



SALICYLIC ACID 6S7 

The contraindications to the use of the elaterium 
are, gastric or intestinal inflammation, extreme exhaus- 
tion, any weak heart condition, and pregnancy. Unlike 
the action of croton oil, and unlike the action of the 
saline cathartics, after the. movements of the bowels 
begin they tend to keep up, causing a large drain of 
water from the system, which becomes very depress- 
ing, and sometimes can be stopped only by the hypo- 
dermatic use of morphin with atropin. This unde- 
sired action of elaterium prevents its frequent use. 

ADMINISTRATION 

The dose of elaterin is from 0.003 to 0.006 gm. 
(from 1/20 to 1/10 grain), and it may be repeated 
once or twice at five-hour intervals, depending on the 
results. 

It is not wise to use elaterin every day or even every 
second or third day, as it causes prostration and may 
cause intestinal inflammation. Consequently, if watery 
catharsis is desired daily, some saline cathartic should 
be selected. 

SALICYLIC ACID 

Salicylic acid may be classed as an antiseptic, as a 
bowel antiseptic and as a "specific" in acute inflamma- 
tory rheumatism or acute arthritis. As a local anti- 
septic it is valuable, but to expensive for extensive 
use. Its greatest value as a local antiseptic is in pow- 
ders and ointments. Salicylic acid in some form rep- 
resents, perhaps, the best bowel antiseptic that can 
be administered. For this purpose some combination 
of it or some salt of it which does not break up and 
become absorbed as quickly as does salicylic acid or 
sodium salicylate is better. The antiseptic action then 
extends farther down to the small intestine. 

INTESTINAL ANTISEPTIC 

While, on the one hand, it is absurd even to consider 
the possibility of rendering the intestinal canal asep- 
tic, it is just as absurd to believe that some form of 
salicylic acid cannot render the upper part of the intes- 
tine less likely to become the abode of bacteria, because 
such would not be the fact. In other words, it is cer- 
tainly possible and is clinically easily demonstrated 



658 SALICYLIC ACID 

that fermentation and putrefaction in the intestine may 
be diminished by the administration of a salt of sali- 
cylic acid, as represented by salol or phenylis salicylas. 
It is. well recognized that the normal hydrochloric acid 
of the stomach tends to inhibit fermentation, not only 
in the stomach, but in the upper part of the intestine. 
It is also recognized that, while normally bile is not a 
germicide, it does inhibit putrefaction in the intestine. 
Salicylic acid has the same power, and perhaps much 
more in acting as a bowel antiseptic. It may be able 
not only to prevent typhoid and other germs, especially 
the colon bacillus, from migrating to the upper part 
of the intestine, but after absorption it may be able to 
prevent these germs from coming to the upper part of 
the intestine, gallbladder, etc., by the lymph and blood 
streams. At any rate, it is a common and every-day 
demonstration that diarrheal disturbances, not chronic, 
but due to acute infection or to poisonous articles of 
food, are stopped and prevented by salicylic acid in the 
form of phenylis salicylas. 

Another advantage of phenylis salicylas is that it 
does not disturb the stomach, not being broken up there 
into its component parts of phenol and salicylic acid, 
i. e., not under ordinary conditions, it being only so 
decomposed in alkaline media. 

It is somewhat irritant to the mucous membranes, 
and for this reason may cause nausea or vomiting and 
a reflex urticaria. 

The signs of its full action are known as "salicyl- 
ism" and are not unlike "cinchonism," i. e., there is a 
fulness of the head, perhaps headache, ringing of the 
ears and sometimes dizziness. With ordinary doses 
of a pure, natural product, i. e., preparations made 
from plants and not synthetically, the heart and circu- 
lation are not disturbed, although the surface blood- 
vessels are dilated, and thus there is caused an 
increased perspiration. If salicylic acid is too long 
administered, by its power to increase nitrogen waste, 
impaired nutrition occurs, and debility is caused. The 
patient also may become anemic, with a tendency to 
hemorrhages and bleeding from the mucous mem- 
branes. Therefore, salicylic acid in any form should 



INTERNAL USES OF SALICYLIC ACID 659 

not be administered in any dosage but minute for 
longer than two weeks at a time as the outside limit. 

INTERNAL ADMINISTRATION 

The ordinary dose of salicylic acid and of sodium 
salicylate are the same, as the former is less soluble 
than the latter, although the latter is naturally the 
weaker preparation. The adult dose in rheumatic 
fever is a gram (15 grains) of either of these prepara- 
tions, administered four times in twenty-four hours, 
or for a few doses, perhaps, at four-hour intervals. 
Symptoms of "salicylism" occurring should cause the 
frequency or the size, of the dose to be decreased. If 
an acute arthritis is not improved in four or five days, 
and certainly in a week, the salicylic acid should ordi- 
narily be stopped. If there is improvement it may be 
continued in smaller doses, two or three times in 
twenty-four hours, for a longer period. 

As the drug is very sweet, it is absurd in admin- 
istering it to add any sweet preparation to disguise 
it, and generally the simplest method of administering 
a drug is the best. If the dose to be administered is 
very small, from 0.01 to 0.25 gm. (from 2 to 4 grains) 
it may occasionally be given in capsule form, but in 
that case it must be given after a meal, as when it 
begins to dissolve it may cause considerable gastric 
pain and even vomiting. This might be prevented by 
a combination with bismuth, as : 

gm. or c.c. 

R Sodii salicylates or 

Bismuthi subnitratis aa 5| gr. lxxv 

M. et fac capsulas, 20. 

Sig. : One capsule, three times a day, after meals. 

If given in liquid form, which is the best way, the 
following is not especially unpleasant: 

gm. or c.c. 

fy Sodii salicylatis 20| or 3v 

Aquae gaultheriae 100| A3 iv 

M. Sig.: A teaspoonful, with plently of water, every six 
hours. 

This could also be administered in some sparkling 
water. 



660 SALOL 

A sodium salicylate is sometimes deemed advisable, 
as follows : 

gm. or c.c. 

fy Acidi Salicylici or 

Sodii bicarbonatis aa 20 1 3v 

M. et fac chartulas, 20. 

Sig. : A powder, in a glass of water, every four hours. To 
drink as effervescence is about completed. 

The oil of wintergreen may be used in place of the 
salicylic acid, if desired. The dose is 1 c.c, or 15 
minims. It may be obtained in elastic capsules and 
thus administered^ but should not be taken on an 
empty stomach. This preparation is sometimes rubbed 
into joints or applied on cotton to the affected parts. 

Methylis salicylas, methyl salicylate, an artificial or 
synthetic oil of wintergreen, is also used externally as 
a liniment in rheumatic conditions. 

SALOL 

Salol, or phenylis salicylas, ordinarily should not be 
used in rheumatic fever. It should also not be used 
when there is any kidney disturbances, as the phenol 
part of the preparation can cause kidney irritation. 
Salol should also rarely be used in very large doses, 
or too long, or in large doses too frequently, as it can 
cause the urine to become dark, indicating phenol poi- 
soning, and it may even cause hemoglobinuria and 
other symptoms of phenol poisoning. The best use of 
salol is as a bowel antiseptic, for which it may be given 
in doses of 0.50 gm. (7y 2 grains) repeated two or 
three times, or doses of 0.30 gm. (5 grains) repeated 
a series of times, or a still smaller dose repeated a 
number of days. 

Salol is also much used in specific urethritis, and is 
valuable in certain forms of cystitis and pyelitis. As 
a bowel antiseptic : 

gm. or c.c. 

I£ Phenylis salicylates 21 or 3 ss 

Bismuthi subnitratis 4| 3i 

M. et fac chartulas, 4. 

Sig. : One powder every three hours. 



EXTERNAL USES OF SALICYLIC ACID 661 

Or: 

gm. or c.c. 

fy Phenylis salicylatis 3\ or gr. xlv 

Bismuthi subnitratis 10| 3 iiss 

M. et fac chartulas, 10. 

Sig. : One powder every two hours. 

For gonorrhea : 

gm. or c.c. 

fy Phenylis salicylatis 5| or gr. lxxv 

M. et fac capsulas, 20. 

Sig. : One capsule every four hours. 

In typhoid fever : 

gm. or c.c. 

R Phenylis salicylatis 4| or 3 J 

M. et fac capsulas, 20. 

Sig. : One capsule every six hours. 

EXTERNAL USES 

The oil of wintergreen is often used externally in 
rheumatic conditions, but the methyl salicylate is prob- 
ably as valuable and much cheaper. Either may be 
used undiluted, applied to the affected joint on absor- 
bent cotton, or a little may be rubbed into the joint, or 
they may be diluted, as : 

gm. or c.c. 

1$ Methylis salicylatis 10 1 or A3 iiss 

Petrolati 25 1 Si 

M. Sig.: Use externally as directed. 

Or the methyl salicylate may be used as a liniment, 
as: 

gm. or c.c. 

f£ Methylis salicylatis 501 or 

Linimentum saponis ad 100| AS ii 

M. Sig. : Use externally as directed. 

Or: 

gm. or c.c. 

R. Methylis salicylatis 50 1 or 

Linimentum chloroformi 100 1 A3 ii 

M. Sig.: Use externally as directed. 

Shoemaker suggests the following three prescrip- 
tions for profuse or fetid perspiration : 

gm. or c.c. 

R Acidi salicylici 10 3 iiss 

Bismuthi subnitratis 15 or 3 iv 

Zinci oleatis 10 3 iiss 

M. Sig. : Use on the parts affected. 



662 EXTERNAL USES OF SALICYLIC ACID 



For eczema with fissures : 

gm. or c.c. 

ty Acidi salicylici 3 gr. xlv 

Betanaphtholis 50 gr. vii 

Unguenti hydrargyri nitratis.. 10 or 3 iiss 
Unguenti zinci oxidi 20 3 v 

M. Sig. : Use externally as directed. 

For dry eczematous patches on the skin : 

gm. or c.c. 

fy Acidi salicylici 2 3 ss 

Bismuthi subnitratis or 

Amyli aa 10 3 iiss 

Adipis lanae hydrosi 30 Si 

M. Sig. : Use externally as directed. 

The following may be used for pruritus : 



gm. or c.c. 

I£ Zinci oxidi 51 3 iss 

Phenolis liquefacti |25 or Tr\ iv 

Acidi salicylici 150 gr. vii 

Petrolati albi. 30| Si 

M. Sig.: Use externally as directed. 

The following may be used for profuse, oily secre- 
tion of the skin : 



9 



Acidi salicylici 

Olei olivae 15 

Adipis lanae hydrosi 20 

Aquae rosae 25 

M. Sig.: Use externally as directed. 



gm. or c.c. 

1 



gr. xv 

flSss 

3v 

fl3 v i 



INDEX TO SUBJECTS 



PAGE 

Abbreviations used in prescription-writing 26 

Acidosis in diabetes mellitus 308 

Acne, boric acid in 486 

Adrenal substance and preparations: see Epinephrin. 

Albuminized milk 581 

water 581 

Alcoholism, cerebral edema in 412 

sugar in treatment of . . . . . 413 

Allergy: see Anaphylaxis. 

Aloes ; . 647 

Alopecia 461 

congenitalia 461 

prematura 462 

prophylaxis of , 465 

treatment of . . . 467 

Amenorrhea, thyroid in 365 

Amyl nitrite, action of 637 

Anaphylaxis 593 

calcium in preventing 600 

definition of 595 

manifestations of 597 

Anemia 348 

pernicious 351 

pernicious, arsenic in ; 351 

pernicious, radiotherapy in 352 

pernicious, splenectomy in 351 

Anesthesia 582 

bladder and kidney complications following 585 

essentials of safe 582 

lung complications following 587 

nausea and vomiting: following 585 

Anesthetist, duties of 583 

Angina pectoris 341 

Anthelmintics 286 

Antipyrin in whooping cough 91 

Antidysenteric serum 264 

Antitetanus serum in tetanus 147 

Antithyroid preparations 374 

Antitoxin in diphtheria 100 

Aortic insufficiency 333 

stenosis 330 

Arrowroot gruel 577 

Arteriosclerosis and calcium 614 

daily laxative in 645 

Arthritis, chronic 142 

chronic, autogenous vaccines in 144 

chronic, treatment of 143 

deformans 145 

deformans, focal infection in. ... ; 145 



664 INDEX 

PAGE 

Ascaris lumbricoides ." 287 

Asphyxia 420 

Dewey method of artificial respiration in. . . . 548 

from submersion 420 

Laborde method of artificial respiration in. ... 548 

livida 547 

Meltzer and Auer method of artificial respiration in 550 

neonatorum 546 

pallida 550 

Schulze method of artificial respiration in 549 

Asthma 226 

cause of 225 

inhalations in , : w 231 

iodids in 227 

paroxysm in, treatment of 229 

treatment of 226 

Atropin in auricular fibrillation 345 

Auricular fibrillation 343 

Autogenous serum: see Serum, autogenous. 

Backache 395 

due to flat-foot 397 

Baldness : see Alopecia 461 

Barley gruel 576 

gruel with broth 576 

water 578 

Baths, cabinet 572 

continuous 572 

sitz 573 

Beebe serum in exophthalmic goiter 360 

Beef eggnog 581 

Benzol in leukemia 354 

Bladder and kidney complications following anesthesia 585 

Blepharitis 425 

Blood, disturbances of 348 

pressure, purgatives to lower 644 

Boils 460 

boric acid in 487 

Bone tuberculosis 196 

Boric acid in acne 486 

in furuncle 487 

in impetigo 488 

in paronychia 489 

in perleche 489 

in skin diseases 486 

in styes 487 

solution as eye wash in measles 71 

Breast feeding 553 

feeding, lack of milk in 556 

Breath, foul 239 

Broken compensation 337 

Bromids 620 

Bronchitis, acute 217 

Browned flour gruel . . . 578 



INDEX 665 

PAGE 

Burns 492 

of eye from lime 431 

Calcium 607 

and arteriosclerosis 614 

in pregnancy 612 

in preventing anaphylaxis 600 

in rickets and osteomalacia 613 

in spasmophilia, tetany and convulsions of infants 614 

in tuberculosis 180, 611 

pharmacology of 609 

preparations of 614 

Camphor in pneumonia 154 

Carbolic acid : see Phenol 590 

Carriers, diphtheria 93 

diphtheria, kaolin in treatment of 96 

diphtheria, staphylococcus pyogenes aureus in treatment of 95 

diphtheria, treatment of 94 

Cascara sagrada 645 

in intestinal stasis 276 

Cathartics 642 

Catheterization in hypertrophy of prostate 512 

Cerates and ointments 18 

Chapped hands 477 

Chicken-pox 109 

Chilblain 478 

Children, acute nephritis in 297 

dosage for 27 

incontinence of urine in 563 

Chinosol,- N.N.R, 4 as disinfectant 591 

Chloral 624 

in tetanus 149 

poisoning 626 

Chloralum hydratum, U. S. P 626 

Chlorbutanol 628 

Chlorid of lime as disinfectant 590 

Chlorosis 350 

Cholera 150 

epinephrin in 151 

Chorea 375 

Circulatory and nervous system, poisoning by depressants of 42 

depressants 637 

Colic 555 

Constipation: see also Intestinal Stasis. 

Constipation, spastic 277 

treatment 643 

Convulsions, infantile 561 

infantile, lime in 614 

Copaiba and santal in gonorrhea 497 

Copper sulphate as disinfectant 590 

Corrosive poisoning, treatment of 39 

Coryza, acute 207 

gargles and sprays in 211 

Coughs 214 



666 INDEX 

PAGE 

Creosote in tuberculosis 181 

Cresol and compound cresol solution as disinfectant 591 

Cretinism, thyroid in 370 

Croton oil 654 

Curettage in uterine hemorrhage 539 

Cystinuria 303 

Delirium tremens 409 

Depressants, circulatory 637 

of nervous and circulatory system, poisoning by 42 

Dermatitis, Roentgen 473 

Dewey method of artificial respiration 548 

Diabetes insipidus 310 

mellitus 305 

mellitus, acidosis in 308 

mellitus, complications and sequelae 309 

mellitus, diet in 305 

Diet in acute mild endocarditis 324 

in diabetes 305 

in dysentery 262 

in hyperthyroidism 359 

in intestinal stasis 274 

in measles 72 

in obesity 312 

in pellagra 203 

in pneumonia 153 

in scarlet fever 80 

in typhoid 130 

in whooping cough 88 

Diphtheria 93 

and diseased tonsils , 106 

antitoxin in 100 

* care of heart in 103 

care of throat in 100 

carriers 93 

gargle in 102 

immunity in 97 

isolation in 98 

laryngeal , 106 

paralysis of 105 

Schick reaction in 97 

treatment of 98 

Diseases, general 66 

general, individual tendencies and family history in 76 

Disinfectants during course of disease, use of 589 

liquid 590 

Disinfection 588 

in scarlet fever 76 

terminal 591 

DobelPs solution 240 

Dropsy, jalap in 653 

Drowning 420 



INDEX 667 

PAGE 

Drug addictions, Jenning's treatment of 404 

addictions, Lambert-Towns method in 399 

addictions, Pettey's method in 402 

addictions, Sceleth treatment of . . 404 

dosage of 27 

dosage of, for children 27 

eruptions 600 

frequency of administration of 29 

Drugs, classification of 33 

idiosyncrasy to 29 

incompatibility of 22 

methods of administering 31 

synonyms for names of 18 

Useful 55 

Dry hot air, local application of 566 

Duodenum, ulcer of stomach and 267 

ulcer, hemorrhage in 4 treatment of 272 

ulcer, operative indications in 273 

ulcer, treatment of 270 

Dysentery, acute 261 

amebic., treatment of 265 

bacillary, treatment of 264 

diet in 262 

Dysmenorrhea 541 

thyroid and ovarian extract in 543 

Dyspnea in tuberculosis 192 

Ear, diseases of 433 

solutions for use in 435 

Eclampsia 521 

stimulation in 523 

thyroid in 368 

vaccines and serums in 530 

Eczema, hyperkeratotic, of palms and soles 474 

picric acid in 490 

prescription for 662 

thyroid in 367 

Edema, cerebral, in alcoholism 412 

Egg and sherry gruel 577 

broth 580 

Eggyolk : see Lecithin 616 

Eggnog 580 

beef 581 

junket 580 

Elaterin 655 

Endocarditis 323 

acute mild 323 

acute mild, diet in 324 

chronic 327 

malignant 325 

Epilepsy 377 

bromids in 621 

thyroid in 369 

Epinephrin in cholera 151 

in hay fever , , r f 233 



668 INDEX 

PAGE 

Eruptions, drug 600 

Erysipelas 156 

picric acid in 491 

Ether, contraindications of. 588 

Evacuants 642 

Exercise in obesity 313 

Eye, burns of, from lime 431 

diseases of 424 

wash in measles, boric acid solution as 71 

Eye-strain and headache 382 

Family history and disease 66 

Farina gruel 578 

Febricula 602 

Feces, anilin gentian violet stain for, in determination of pathologic 

ova 256 

examination of 251 

Fermentation in stomach, rarity of . 260 

Flat-foot, backache due io 397 

Flexner serum in meningitis 113 

Flour gruel 576 

Focal infection in arthritis deformans 145 

in hyperthyroidism 360 

Formaldehyd as disinfectant 591 

Frostbite 480 

Furuncles : see Boils 460 

Gargles 241 

and sprays in scarlet fever 82 

and sprays in whooping cough. 89 

Gas, illuminating., poisoning 413 

Gastro-intestinal tract, diseases of 237 

irritants of 37 

Genito-urinary tract, diseases of 495 

tuberculosis of 195 

Gentian violet stain, anilin, for feces in determination of pathologic 

ova 256 

German measles 108 

Goiter, exophthalmic: see Hyperthyroidism 358 

Gonorrhea, acute 495 

astringents in . 501 

copaiba and santal in 497 

irrigations in 500 

local treatment of 499 

serum and vaccine therapy of -. 503 

Gout 311 

Grip : see Influenza 219 

Gruels 575 

Gynecology and obstetrics 515 

Hall method of artificial respiration 421 

Harrison antinarcotic law 24 

Hay fever 233 

epinephrin in 233 

pollen serums in 234 



INDEX 669 

PAGE 

Headache 381 

acetanilid in 385 

and eye-strain 382 

treatment of 384 

Heart attack, acute 336 

block 347 

broken compensation. 337 

care of.- in diphtheria 103 

care of, in pneumonia 155 

chronic valvular disease of 327 

compensated 328 

disturbances of v 316 

disturbances^ prevention of 316 

in scarlet fever 83 

Heat exhaustion and sunstroke, after effects of 419 

prostration 415 

Height, table of average, at different ages 28 

Heliotherapy in tuberculosis 185 

Hemoptysis in tuberculosis 188 

Hemorrhage in duodenum ulcer, treatment of 272 

postpartum 534 

uterine 534 

Herpes labialis, picric acid in 491 

Hodgkin's disease 356 

Hookworm disease 122 

thymol in 123 

Hordeolum: see Stye 427 

Hot air, dry, local application of 566 

Howard method of artificial respiration 421 

Hydrotherapy , 571 

in mental diseases 571 

in obesity 313 

in urology 573 

Hyperacidity 281 

treatment of 283 

Hyperthyroidism 358 

diet in 359 

excitability in 359 

infective foci in 360 

rest in treatment of 359 

roentgenotherapy in 361 

sodium phosphate in 364 

specific preparations in . 361 

surgery in 361 

thymus in 361 

treatment of 358 

Hypnotics 620 

Hypophosphites in tuberculosis 183 

Hypothyroidism 365 

and pregnancy 516 

Hyoscin : see Scopolamin 633 

Hysteria, thyroid in 36? 

Ichthyol 182, 619 



670 INDEX 

PAGE 

Idiosyncrasy to drugs 29 

Illuminating gas poisoning 413 

Impetigo; boric acid in 488 

contagiosa 456 

Indian meal gruel 577 

Indigestion 257 

Infancy, diseases of 552 

Infant, colic in 555 

convulsions of 561 

convulsions of, lime in 614 

digestion in, influence of posture on 556 

feeding, cow's milk in 558 

feeding, supplementary foods in 557 

mortality and feeding 552 

weaning of 558 

wet nursing 558 

Infection, local septic, dry hot air in 569 

Influenza 219 

treatment of ; . . 221 

Intertrigo, picric acid in 491 

Intestinal antiseptic, salicylic acid as 657 

stasis 274 

stasis and habit 275 

stasis, diagnosis of 280 

stasis, diet in 274 

stasis, massage in 275 

stasis, medicinal treatment 276 

stasis, symptomatology of 279 

stasis, treatment of 281 

Intoxication 399 

Iritis 427 

Irritants of central nervous system 40 

of central nervous system, poisoning by, treatment of 41 

of gastro-intestinal canal 47 

Itching : see Pruritus 436 

Jalap 652 

in dropsy 653 

Jennings' treatment of drug addictions 404 

Junket eggnog 580 

Kaolin in treatment of diphtheria carriers 96 

Karrell treatment of chronic nephritis 299 

Kendall's preparation of thyroid 373 

Kidney and bladder complications following anesthesia 585 

diseases of 290 

tuberculosis 293 

Kresamine as disinfectant 591 

Labor de method of artificial respiration in asphyxia neonatorum... 548 

Lambert-Towns method in drug addictions 399 

Laryngeal diphtheria 106 

tuberculosis 193 

Latin in prescriptions 25 

rules for cases in prescriptions 25 

Laxative, aloes as 648 

daily, in arteriosclerosis 645 



INDEX 671 

PAGE 

Lead-poisoning 406 

Lecithin , 616 

Leukemia 353 

benzol in 354 

roentgenotherapy in 354 

Lichen planus 482 

Lime: see also Calcium 607 

Lime, burns of eye from 431 

Liniment, methyl salicylate as 661 

Liquor calcis, U. S. P 615 

Lumbago 398 

Lung complications following anesthesia 587 

Magnesium oxid 640 

sulphate in tetanus 148 

Massage in intestinal stasis 275 

Measles 69 

boric acid solution as eye wash in 71 

care of bowels in 72 

cough in 72 

convalescence 73 

diet in 73 

fever in 73 

prophylaxis of 69 

treatment of 71 

Measures and weights 19 

Meltzer and Auer method of artificial respiration 550 

Meningitis 112 

Flexner serum in 113 

meningococcus vaccines in 113 

treatment 113 

tuberculous 196 

Meningococcus vaccines 113 

Mental diseases, hydrotherapy in 571 

Mercuric chlorid solution as disinfectant 590 

Mercury in syphilis 161 

Metabolism, diseases of 305 

Methyl salicylate as a liniment 661 

Metric system 19 

Milk, albuminized 581 

cow's, in infant feeding 558 

lack of, in breast feeding 556 

of magnesia 640 

sterilization and pasteurization of 560 

Mitral insufficiency 329 

insufficiency, digitalis in 333 

stenosis 328 

Moebius' antithyroidin 374 

Morphin addiction, Pettey's method in 402 

Mouth, hygiene of 237 

washes 241 

Mumps 110 

treatment Ill 

Myocarditis, acute 320 

chronic 321 



672 INDEX 

PAGE 

Myocardium, disturbances of 320 

Myxedema, thyroid in 369 

National formulary 14 

Nausea and vomiting following anesthesia 585 

Neosalvarsan in syphilis 160 

Nephritis, acute 294 

acute, in children 297 

care of heart in 299 

chronic 298 

chronic, Karell treatment of 299 

due to scarlet fever 84 

Nerve blocking in sciatica 392 

Nervous and circulatory system, poisoning by depressants of 42 

system, diseases of 375 

" ! system, syphilis of 166 

New and Nonofficial Remedies 48 

Night-sweats in tuberculosis 191 

Nitrites 637 

Nitroglycerin 638 

Nose, care of, in scarlet fever 82 

Nutrition, supporting, in pregnancy 519 

Oatmeal gruel 578 

water 579 

Obesity 311 

diet in 312 

exercise in 313 

hydrotherapy in 313 

infantile, thyroid in 366 

medicinal treatment of 314 

Ointments and cerates 18 

Oleum tiglii, U. S. P 654 

Ophthalmia neonatorum 424 

Osteomalacia, lime in rickets and 613 

Otitis media " 433 

Ova, pathologic, anilin gentian violet stain for feces in determina- 
tion of 256 

Ovarian and thyroid extract in dysmenorrhea 543 

Oxyuris vermicularis 288 

Packs, hot and cold 575 

Pain as a symptom 68 

Paracentesis in acute pericarditis „ . . . 319 

Paraldehyd 628 

Paralysis, diphtheric 105 

in poliomyelitis 121 

Paronychia, boric acid in 489 

Parotitis : see Mumps 110 

Pasteurization and sterilization of milk 560 

Pellagra 201 

diet in 203 

treatment of 202 

Pericarditis, acute 317 

acute, alkalies in 317 

acute, ergotin in 318 

acute, paracentesis in 319 

acute, cold applications in 317 



INDEX 673 

PAGE 

Peritonitis, tuberculous 193 

Perleche, boric acid in 489 

Perspiration of feet, treatment of 492 

prescription for 661 

Pettey's method in drug addictions 402 

Pharmacopeia 14 

Pharyngitis, acute 213 

Phenoco as disinfectant 591 

Phenols as disinfectant 590 

Phenylis salicylas: see Salol. 

Phosphorus 616 

Physical therapy 566 

Physicians, transmission of disease by ... 78 

Picric acid in eczema 490 

in erysipelas 491 

in herpes labialis 491 

in intertrigo 491 

in skin diseases 490 

Pin Worms : see Oxyuris vermicularis 288 

Pneumonia 152 

camphor in 154 

care of heart in 155 

convalescence in 156 

diet in . . . 153 

treatment of 152 

vaccine treatment of 156 

Pneumonic type of pulmonary tuberculosis 193 

Podophyllum or mayapple 646 

Poisoning by depressants of nervous and circulatory system 42 

by irritants of central nervous system, treatment of 41 

chloral 626 

corrosive 39 

treatment of 40 

Poisons, table of special symptoms and special treatment of various. . 44 

Poliomyelitis, acute anterior 117 

acute stage of 117 

local treatment 120 

paralysis of, treatment of 121 

Pollen serums in hay fever 234 

Postpartum hemorrhage 534 

Posture, influence of, on digestion in infant 556 

Potassium bromid 623 

permanganate as disinfectant 590 

salts in rheumatism 140 

Pregnancy, calcium in 612 

displacement of uterus in 518 

hypothyroidism and 516 

nutrition in 519 

toxemias of 515 

vomiting of ' 517 

vomiting of, thyroid in 367 

Prescribing, unscientific 67 

Prescription writing 13 

writing, abbreviations used in 26 



674 INDEX 

PAGE 

Prescriptions, Latin in 25 

Latin rules for cases in 25 

Proprietaries, prescribing 14 

Prostate, chronic hypertrophy of 507 

hypertrophy of, catheterization in 512 

hypertrophy of, operation in 513 

Prostatitis and seminal vesiculitis 503 

Protein poisoning 593 

Pruritus 436 

ani 442 

prescription for 662 

vulvae 446 

Psoriasis 457 

autogenous serum in 459 

Puerperal infection 524 

prevention of 526 

replies to questionaire on treatment of 532 

treatment of 527 

Pulmonary insufficiency 335 

stenosis 336 

Purgatives to lower blood pressure 644 

Pyelitis 290 

treatment of 291 

Pyorrhea alveolaris 246 

Quinin irrigations in amebic dysentery 266 

Respiration, artificial 420 

Respiratory tract, diseases of the 206 

Rhamnus purshiana: see Cascara Sagrada 645 

Rheum as a cathartic 650 

Rheumatism 139 

dry hot air in 568 

potassium salts in 140 

salicylates in 139 

treatment of 139 

tuberculous 198 

vaccine treatment of 142 

Rhubarb : see Rheum 650 

Rice gruel 577 

water 579 

Rickets, lime in osteomalacia and 613 

Ringworm 448 

roentgenotherapy in 450 

Roentgen dermatitis 473 

Roentgenotherapy for perspiration of feet 492 

in hyperthyroidism 361 

in leukemia 354 

in pernicious anemia 352 

in ringworm 450 

in tinea tonsurans 452 

in uterine hemorrhage 539 

Round Worm : see Ascaris Lumbricoides 287 

Sacro-iliac strain 397 

Salicylates in rheumatism 139 



INDEX 675 

PAGE 

Salicylic acid 657 

as intestinal antiseptic 657 

internal administration of 659 

Salines following operation 586 

Salol 660 

external uses of 661 

in typhoid 135 

Salvarsan in syphilis 160 

Salvarsanized serum in syphilis 166 

Santal and copaiba in gonorrhea 497 

Scabies 446 

sulphur in 448 

Scarlet fever 74 

bathing in 82 

care of nose in 82 

care of skin in 82 

cervical glands in 79 

contagiousness of 75 

convalescence in 85 

diet in 80 

disinfection in ■ 76 

gargles and sprays in 82 

heart in 83 

isolation in 76 

late complications in 83 

middle ear inflammations in 83 

nephritis due to 84 

prophylaxis of 74 

treatment of fever in 81 

vaccines in 85 

Sceleth treatment of drug addictions 404 

Schafer method of artificial respiration 422 

Schick reaction in diphtheria 97 

Schulze method of artificial respiration in asphyxia neonatorum 549 

Sciatica 388 

medicinal treatment of 394 

nerve blocking in 392 

stretching the nerve in 391 

vaccine treatment of 393 

Scopolamin 633 

and morphin analgesia in obstetrics 636 

Seminal vesiculitis 503 

Serums and vaccines in eclampsia 530 

and vaccines in gonorrhea 503 

antidysenteric 264 

in hyperthyroidism 360 

Sitz bath 573 

Skin, care of, in scarlet fever 82 

diseases 436 

diseases, boric acid in '. 486 

diseases, picric acid in 490 

diseases, vaccine therapy in 484 

oily secretion of, prescription for 662 



676 INDEX 

PAGE 

Sodium bromid 623 

bromid, intraspinous injections of, in delirium tremens 412 

dichromate and sulphuric acid in terminal disinfection 592 

nitrite 640 

phosphate in exophthalmic goiter. 364 

Spasmophilia, lime in 614 

Spiritus glycerylis nitratis 639 

Splenectomy in pernicious anemia 351 

Sprains, dry hot air in 567 

Staphylococcus pyogenes aureus in treatment of diphtheria carriers. . 95 

Starchy drinks 575 

Sterilization and pasteurization of milk 560 

Sterility in women 544 

Stomach contents, examination of 247 

contents, removal of 248 

digestion, importance of 258 

fermentation in, rarity of 260 

interpretation of symptoms referable to 257 

relation of, to other organs 258 

symptoms not characteristic of disease of ' 259 

ulcer of duodenum and 267 

ulcer, symptoms of 268 

Streptococcus pyogenes and septic sore throat 107 

Struma, simple, of thyroid 364 

Stye 427 

boric acid in 487 

Sugar in treatment of alcoholism 413 

Sulphonal 630 

chronic poisoning from 631 

Sulphur dioxid in terminal disinfection 592 

in scabies 448 

Sunstroke 415 

and heat exhaustion, after effects of 419 

treatment of 417 

Swift-Ellis treatment of syphilis 166 

Sylvester method of artificial respiration 421 

Synonyms for names of drugs 18 

Syphilis 159 

care of mouth in 166 

care of primary lesion 160 

early treatment of 160 

iodids in 164 

mercury in 161 

of nervous system 166 

salvarsan and neosalvarsan in 160 

salvarsanized serum in 166 

Swift-Ellis treatment of 166 

Tapeworm 285 

Teeth, care of 244 

hygiene of, 237 

Test meal 247 

Tetanus 146 

antitetanus serum in 147 

chloral in 149 

magnesium sulphate in 148 

prevention of 146 

treatment of 147 



INDEX 677 

PAGE 

Tetany, lime in 614 

Thermometric equivalents 19 

Thymol in hookworm disease 123 

Thymus in hyperthyroidism 361 

Throat, care of, in diphtheria 100 

septic sore 107 

Thyroid, administration of 372 

and ovarian extract in dysmenorrhea 543 

contraindications to administration of 372 

disturbances of 358 

hyposecretion of 365 

in chlorosis 350 

in cretinism 370 

in eclampsia 368 

in eczemas 367 

in epilepsy 369 

in hysteria 367 

in infantile obesity 366 

in myxedema 369 

in vomiting of pregnancy 367 

Kendall's preparation of 373 

official preparation of 372 

principal uses of 365 

simple struma of 368 

unclassified uses of 371 

Tinea cruris 454 

tonsurans, roentgenotherapy in 452 

trichophytina : see Ringworm '. . 448 

Toast water 579 

Tonsils, diseased, and diphtheria 106 

Toxemias of pregnancy 515 

Transmission of disease by physicians 78 

Tricuspid insufficiency 334 

stenosis 335 

Trikresol, N. N. R., as disinfectant ' , 591 

Trional 632 

Tuberculin in tuberculosis 177, 184 

Tuberculosis 169 

acute miliary 197 

arrested 200 

arsenic in 183 

bone and joint 196 

calcium in 180, 611 

cervical glands 195 

cod-liver oil in 182 

cough in, treatment of 185 

creosote in 181 

diarrhea in 192 

dyspnea in 192 

etiology of 169 

fever in, treatment of 185 

genito-urinary tract 195 

heliotherapy in 185 

hemoptysis in 188 



678 INDEX 

PAGE 

Tuberculosis, continued. 

hypophosphites in 183 

ichthyol in 182 

in children 171 

iodin in 184 

kidney 293 

laryngeal 193 

measures that will cause decrease in incidence of 172 

night-sweats in 191 

pretuberculosis symptoms 173 

prognosis in 198 

pulmonary, ichthyol in 619 

pulmonary, pneumonic type of 193 

temperature in 175 

tuberculin in 177, 184 

Tuberculous meningitis 196 

peritonitis 193 

rheumatism 198 

Twilight slumber 637 

Typhoid fever 125 

colon enemas in 133 

convalescence in 139 

diet in 130 

general prophylaxis of 125 

hexamethylenamin in 131 

hydrotherapy in 134 

rules for preventing 127 

salol in 135 

treatment of 130 

vaccination against 128 

vaccine therapy of 136 

Typhus fever 158 

Ulcer, duodenum, hemorrhage in, treatment of 272 

duodenum operative indications in 273 

duodenum, treatment of . . . .' 270 

stomach and duodenum 267 

stomach, symptoms of 268 

Uncinariasis: see Hookworm Disease 122 

Urinary antiseptics 497 

Uremi? 302 

Urine, incontinence of, in children 563 

Urology, hydrotherapy in 573 

Urticaria 471, 602 

giant 602 

Uterus, displacement of, in pregnancy . 518 

hemorrhage 534 

hemorrhage, curettage in 539 

hemorrhage, medical treatment of 540 

hemorrhage, roentgenotherapy in 539 

Vaccination against typhoid fever 128 

Vaccines and serums in eclampsia 530 

and serum therapy of gonorrhea 503 

autogenous, in chronic arthritis 144 

in pneumonia . . 156 



INDEX 679 

PAGE 

Vaccines and serums, continued. 

in rheumatism 142 

in scarlet fever . , 85 

in sciatica 393 

in skin diseases 484 

in typhoid 136 

in whooping cough 90 

meningococcus 113 

Varicella : see Chicken-Pox 109 

Vomiting and nausea following anesthesia 585 

of pregnancy 517 

of pregnancy, thyroid in 367 

Vulva, pruritus of 446 

Water, albuminized 581 

Weaning of the infant 558 

Weights and measures 19 

table of average, at different ages, 28 

Wet nursing 558 

Whooping cough 86 

antipyrin in 91, 92 

diet in 88 

prophylaxis of 86 

sprays and gargles in 89 

treatment of 88 

vaccine treatment of 90 

Wintergreen, oil of 661 

Zinc chlorid as disinfectant 590 



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